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COPYRIGHT DEPOSm 



DISEASES 

OF 

INMTS AID CHILDREN 

BY 

HENRY DWIGHT CHAPIN, A.M., M.D. 

'/ 

PROFESSOR OF DISEASES OF CHILDREN, NEW YORK POST-GRADUATE MEDICAL SCHOOL AND 
HOSPITAL; SUPERVISING PHYSICIAN OF THE CHILDREN'S DEPARTMENT, NEW YORK 
POST-GRADUATE HOSPITAL ; CONSULTING PHYSICIAN TO THE WILLARD PARKER 
HOSPITAL ; TO THE RANDALL'S ISLAND HOSPITAL ; TO ST. AGNES 
HOSPITAL, WHITE PLAINS ; TO CONVALESCENT HOME FOR 
CHILDREN. SEA CLIFF. AND TO THE HACKENSACK 
HOSPITAL ; EX-PRESIDENT OF THE AMERI- 
CAN PEDIATRIC SOCIETY 

AND 

GODFREY ROGER PISEK, M.D., Sc.D. 

PROFESSOR OF DISEASES OF CHILDREN AND ATTENDING PHYSICIAN TO THE NEW YORK POST- 
GRADUATE MEDICAL SCHOOL AND HOSPITAL; PROFESSOR OF DISEASES OF CHILDREN, 
UNIVERSITY OF VERMONT, MEDICAL COLLEGE ; VISITING PHYSICIAN TO 
THE WILLARD PARKER AND RIVERSIDE HOSPITALS | PEDIATRIST TO 
THE PARK HOSPITAL ; CONSULTING PEDIATRIST TO THE 
DARRACH HOME FOR CHILDREN AND TO THE 
UNION HOSPITAL, PORTCHESTER 

THIRD REVISED EDITION 



WITH ONE HUNDRED AND SEVENTY-NINE CUTS 
AND TWELVE COLORED PLATES 



NEW YOBK 
WILLIAM WOOD AND COMPANY 

MDCCCCXV 







vPl-l 



COPYRIGHT, 1915 

By WILLIAM WOOD AND COMPANY 



First Edition, August, 1909 

Reprinted, August, 1910 

Second Edition, September, 1911 
Reprinted, August, 1912 
Reprinted, April, 1913 

Third Edition, August, 1915 



fi 



W 



HAMILTON PRINTING CO. 
ALBANY, N. Y. 

©PU414094 

QGT 18 i 3 1 5 

"Ha , / -' 



TO 

THE STUDENTS 

BOTH GRADUATE AND UNDERGRADUATE 

IN THE 

UNITED STATES AND CANADA 

WHOM IT HAS BEEN OUR PLEASURE TO TEACH 

THIS 

BOOK IS DEDICATED. 



PREFACE TO THE THIRD EDITION. 



The repeated printings of this book have necessitated the making of 
new plates. This has given us an opportunity to thoroughly revise the 
text bringing each section into accord with the advances which are con- 
stantly being made in this specialty. 

The section on Infant Feeding has been recast and new topics added, 
such as albumen-milk feeding; special diet lists for older children; and 
the action of catalyzers. 

In the Infectious Diseases the Schick and the luetin tests have been 
described. Mental tests especially adapted for the early months of life 
have been included, owing to the widespread interest in prophylactic 
pediatrics. 

Many of the photographs have been replaced with new ones when it 
was thought that such a change would further add to the value of the 
descriptive matter. 

By a change of type the rarer and the less important diseases have 
been differentiated, and the book thus made more practical for teaching 
purposes. 

It is hoped that the need for a work as compact as is consistent with 
thoroughness and completeness will insure the same kind reception which 
has thus far been accorded it by the profession. 

The unfailing courtesy and helpful suggestions of the publishers are 
hereby acknowledged with thanks. 

H. D. C— G. E. P. 
July 1st, 1915. 



PREFACE TO THE FIRST EDITION. 



This volume has been written by teachers who feel that a large 
contact with students has made them fairly familiar with their needs. 
Probably the first requirement at present is to bring each branch of medi- 
cine into as compact a form as is consistent with a thorough presentation 
of the subject. Our aim has been to accomplish this with pediatries. To 
many, the diagnosis and treatment of diseases of infants and children are 
most perplexing. These difficulties can only be overcome by first sharply 
differentiating the anatomical and physiological peculiarities of the infant 
and child, and then considering their practical bearings. 

The student must be familiarized with all the more recent tests, as 
well as the older practical bedside experience, in the study of disease. He 
will then, by a systematic examination of the patient, be able to make a 
scientific diagnosis. He must also be taught to treat rationally and with 
a distinct purpose in mind. We have aimed to present the subject in 
this way. and thus to make the work as practical as possible. The physician 
needs such a description of disease as he will actually encounter at the bed- 
side. Where pictures can serve as a type, we have used illustrations, most 
of which are original. Theory and pathology have only been considered 
in so far as may be necessary to an understanding of the diagnosis, course 
and treatment of disease. "We have tried to take a middle course between 
the compendium, which is usually unsatisfactory, and a too exhaustive 
work, which, by dwelling over much on theory and exceptions, tends to 
confuse the reader. 

Our thanks are due to our hospital assistants, Drs. Dennett and Albee, 
for their help during the progress of the work. While a book of this sort 
must be indebted to all the workers in pediatrics, whom we have freely 
consulted, our personal experience at the Infants' and Children's Wards 
of the Xew York Post-Graduate Hospital, and in private practice, has 
formed the essential basis of our description of the diseases and their 
treatment. 

Our thanks are due to the publishers for their care and courtesy in 
the preparation of the book. 

The Authors. 

New York, September, 1000. 

vii 



CONTENTS. 



SECTION I. 
The Newly-born. 



CHAPTER I. PAGE 

The Management and Care of Premature Infants 1 

CHAPTER II. 

Injuries During Birth. 

Deformity of Head ; Caput Succedaneum ; Cephalhematoma ; Injuries to 
Bone and Muscle ; Birth Palsies ; Facial Paralysis ; Upper-arm Paralysis 
(Duchennes) ; Central Paralysis; Asphyxia; Congenital Atelectasis; 
Fetal Death 5 

CHAPTER III. 

Diseases of the Newly-born. 

Acute Infectious Diseases ; Sepsis of the Newly-born ; Umbilical Hemor- 
rhage ; Umbilical Vegetations ; Umbilical Hernia ; Epidemic Hemoglobin- 
uria (Winckel's Disease) ; Fatty Degeneration of the Newly-born (Buhl's 
Disease); Icterus Neonatorum; Tetanus Neonatorum; Conjunctivitis; 
Ophthalmia Neonatorum ; Mastitis ; Sclerema Neonatorum ; Spontaneous 
Hemorrhages in the Newly-born 12 

SECTION II. 
Hygiexe of Infancy. 



CHAPTER IV. 

Hygiene of Infancy. 

Clothing; The Nursery; Bathing; Exercise and Fresh Air; General Habits . 2.°> 

CHAPTER V. 
Weight and Development. 

Weight: Length; General Shape; Head; Brain: Spine; Glands; Stomach; 
Intestines and Liver ; Bladder ; Muscles ; Dentition ; Delayed Dentition ; 
Disturbances of Dentition: Care of Temporary Teeth: Permanent Teeth; 
Hutchinson's Teeth: Growth during Childhood: Mental and Moral 

Growth ; Adolescence 20 

ix 



CONTENTS. 
SECTION III. 

The Examination of the Sick Child. 



CHAPTER VI. 

The Examination of the Sick Child. 

Page 
History; Inspection; Palpation; Auscultation; Percussion; Mensuration; 

Rectal Examination 39 

CHAPTER VII. 

Special Examinations. 

Exudates; The Sputum; The Gastric Contents; The Feces; The Cerebrospinal 
Fluid ; Technic for Subdural or Lumbar Puncture; Technic for Aspiration 
of Pleural Cavity: The Urine; Test for Indican ; Thread Reaction in 
Pyelitis; Transudates and Exudates; The Roentgen Rays; Hemoglobin; 
Red and White Blood Counts ; Red Cell Count in Early Life ; White Cell 
Count : Blood Smears ; Nucleated Red Cells in Infants ; The Relation of 
Polynuelear Neutrophiles to Lymphocytes during Childhood; Eosinophilia ; 
Malaria; Widal Test; Tuberculin Tests; Method of Collecting the Serum 
for the Wassermann Test; Syphilis and the Wassermann Reaction; 
Luetin Test 48 

CHAPTER VIII. 

Signs of Illness in Infancy. 

Irritability of Temper; Restless Sleep; Changes in Features; State of the 

Discharges 60 

CHAPTER IX. 

General Therapeutics. 

Drug Administration: Table of Average Doses; Introductory Remarks; 
Psychotherapy; Aerotherapy ; Hydrotherapy; Special Baths; Naso- 
pharyngeal Toilet: Lavage; Enteroclysis ; Gavage; Rectal Feeding; Vac- 
cine Therapy; Exercises . . . • 63 

CHAPTER X. 

Suggestive Scheme for Diagnosis. 
Head: Neck; Faee: Mouth: Swallowing; Abnormalities in Breathing; Chest; 
Abdomen; Inguinal Region; Delayed Growth; Hemorrhages; Extremi- 
tlf ' s 85 



CONTENTS. XI 

SECTION IV. 

Infant-Feeding. 



CHAPTER XL 

The Infant from the Nutritional Standpoint. 

Page 
The Infant ; Essential Unity of Foods ; Foods of the First Nutritive Period ; 
Breast Secretions ; Specialized Foods ; Composition and Properties of 
Breast Secretions ; Development of the Digestive Tract ; Comparative 
Mammary Secretions; Chemical and Biological Standards 93 

CHAPTER XII. 

Breast Feeding. 

Importance of ; Preparation for Maternal Feeding ; Management ; Regularity : 
Milk Agrees : Flow Scanty : Elimination of Drugs and Excretory Products 
in Milk ; Milk Plentiful but Disagrees with Infant : Examination of Breast 
Milk : Nursing not Possible : Contraindications for Nursing ; Weaning and 
Mixed Feeding; Selection of Wet Nurse 99 

CHAPTER XIII. 

Principles of. and Materials Used in Substitute Feeding. 

Difficulties Encountered ; Principles that Apply to All Infants ; Cow's Milk : 
One Cow's Milk : Influence of Breed on Composition : Bacteriology of ; 
Production of Sanitary Milk: Market Milk: Pasteurized and Sterilized 
Milk: Cream: Condensed Milk: Evaporated Milk: Mammala : Cereals: 
General Properties of Carbohydrates of Cereals: Eggs; Dextri-Maltose ; 
Proprietary Infant Foods; Classification of; Analyses of 108 



CHAPTER XIV. 

Rise and Development of Scientific Infant-Feeding. 

Historical : Fundamental Errors Made : Classification of Methods of Modifying 
Milk: Infants tend to adapt themselves to their Food: Infants differ in 
digestion and assimilation efficiency : Assimilation most Efficient in 
Early Infancy 121 



xii CONTENTS. 

CHAPTER XV. 

Practical Feeding. p AGE 

Basis of; Percentage of Milk Mixtures; Top Milk; Percentage Cereal Gruels; 
Outline ol' Feeding Directions; Food for Healthy Infants; Directions for 
Making Gruels; Approximate Home Modification of Whole Milk; Adapta- 
tion oi Food to Infant; Food for Infants Previously Badly Fed; Feeding 
History; Management; Food for Infants of Feeble Constitution; A Wet 
Nurse Unobtainable; Catalysers; Food for the Acutely 111; Eiweissmilk; 
Management of Cases when All Atttempts at Adding Fresh Milk Fail; 
Laboratory Feeding; Caloric Feeding; Finkelstein's Classifications; 
Directions for Mother and Nurse; How to Interpret Results; Feeding in 
Hot Weather : Feeding when Traveling; Feeding when Away from Home; 
Feeding Among the Poor ; Infant's Food Dispensaries 126 

CHAPTER XYI. 

Diet During the Second Year. 
Dietarv Twelfth to Eighteenth Months; Eighteenth to Twenty-fourth Months; 
Two to Three Years: Three to Six Years; Diet List for Children's Hos- 
pitals: Diet Lists for Day Nurseries and Creches; Diet During Later 
Childhood; Suggestive Diets for Special Conditions 157 

SECTION V. 

Diseases of the Digestive System. 



CHAPTER XVII. 
Diseases of the Mouth. 

General Considerations ; Desquamative Glossitis ; Simple Stomatitis ; Aphthous 
Stoiii.n it is : Bednar's Aphthae; Perleche; Mycotic Stomatitis (Thrush); 
Ulcerative Stomatitis: Gangrenous Stomatitis (Noma) ; Elongated Uvula. 169 

CHAPTER XVIII. 
Diseases of the Digestive Tract. 
Corrosive Esophagitis ; Congenital Occlusion of the Esophagus; Acute Gastric 
Indigestion (Acute Gastritis) ; Gastric Ulcer; Chronic Gastritis; Dilata- 
tion of the Stomach; Stenosis of the Pyloris and Pyloric Spasm; 
Recurrent or Cyclic Vomiting; Infant's Stools; Colic; Acute Gastro- 
enteritis: Acute Enterocolitis ; Chronic Gastrointestinal Indigestion; 
Congenita] Dilatation of the Colon (Hirschprung's Disease) ; Cholera 
[nfanum; Constipation; Amebic Dysentery 176 

CHAPTER XIX. 

The Animal Parasites. 

sitlc Protozoa; Oxyuria Vermicularis ; Ascaris Lumbricoides ; Cestodes 

<>r Tape-worms; Tenia Mediocanellata ; Tenia Solium; Uncinaria Duo- 

denalis; Trichina spimiis 201 



CONTEXTS. Xlll 

CHAPTER XX. 

Diseases of the Liver. 

Page 
The Liver ; Examination of the Liver ; Jaundice ; Inflammation of the Biliary 
Ducts ; Inflammation of the Portal Vein ; Congestion of the Liver ; Fatty 
Liver; Amyloid Liver; Cirrhosis of the Liver; Abscess of the Liver . . 209 

SECTIOX VI. 
The Infectious Diseases. 



CHAPTER XXI. 

The Infectious Diseases. 

Measles ; German Measles ; Scarlet Fever ; Variola ; Vaccination ; Varicella ; 
Table of Exanthemata ; Diphtheria ; Pertussis ; Mumps ; Typhoid Fever ; 
Influenza ; Influenzal Meningitis ; Syphilis ; Cerebrospinal Meningitis ; 
Poliomyelitis ; The Epidemic Form in Children ; Rheumatic Fever ; 
Malaria (Paludism) Erysipelas; Disinfection 214 

CHAPTER XXII. 

Tuberculosis. 

Etiology ; Tuberculosis Adenitis ; Thoracic Tuberculosis in Children ; Pul- 
monary Tuberculosis (Acute and Chronic) ; Acute Miliary Tuberculosis; 
Tuberculous Meningitis : Tuberculous Peritonitis ; Tuberculosis of Bones 
and Joints: Tuberculosis of the Vertebrae; Tuberculous Disease of the 
Hip; Tuberculous Disease of the Knee; Treatment of Tuberculosis in 
General 302 

SECTIOX VII. 
Diseases of the Eespieatory Teact. 



CHAPTER XXIII. 

Diseases of the Upper Respiratory Tract. 

Acute Rhinitis ; Epistaxis ; Foreign Bodies in the Nose ; Examination of the 
Infant's Throat: Pharyngitis and Tonsillitis in Infants: Acute Pharyngi- 
tis; Acute Follicular Tonsillitis: Uleero-membranous Tonsillitis (Vin- 
cent's Angina); Streptococcus Sore Throat: Chronic Tonsillar Hyper- 
trophy; Adenoids: Peritonsillar Abscess: Retropharyngeal Abscess; Acute 
Laryngitis ('Spasmodic Croup): Edema of the Glottis: Laryngismus 
Stridulus; Congenital Laryngeal Stridor: New Growths in Larynx . . . .°>2f> 



x i v CONTENTS. 

CHAPTER XXIV. 

Diseases of the Lungs and Pleura. 

Page 

Acute Bronchitis; Chronic Bronchitis; Pulmonary Collapse; Emphysema; 
Bronchial Asthma; Acute Bronchopneumonia; Hypostatic Pneumonia; 
Lobar Pneumonia; Pleurisy, Dry, Serofibrinous; Empyema; Pneu- 
mothorax; Pulmonary Abscess; Gangrene of the Lung; Bronchiectasis; 
Foreign Bodies in the Respiratory Tract ; Subphrenic Abscess .... 34a 



SECTION VIII. 
Diseases of the Circulatory System. 



CHAPTER XXV. 

Diseases of the Heart. 

The Heart: Congenital Heart Disease (Cyanosis); Endocarditis; Myo- 

carditis 364 

CHAPTER XXVI. 

Chronic Valvular Disease. 

Mitral Regurgitation; Mitral Obstruction; Aortic Obstruction; Aortic Regur- 
gitation : Tricuspid Regurgitation; Functional Cardiac Disorders . . . 372 

CHAPTER XXVII. 

Diseases of the Pericardium. 

Pericarditis; Instruments of Precision in Cardiac Disease 378 

SECTION IX. 
Diseases of ttti- Blood and Ductless Glands. 



CHAPTER XXVIII. 

Diseases of the P>lood. 

Glossary; The Blood; Anemia; Simple or Secondary Anemia; Chlorosis; 
Pernicious Anemia; Leukemia; Pseudo-leukemia of Infants (von Jaksch's 
Anemia); Table of Anemias; Treatment of the Anemias; Purpura; 
Purpura Simplex; Purpura Hemorrhagica; Henoch's Purpura; Schonlein's 
Purpura ; Hemophilia 381 



CONTENTS. XV 

CHAPTER XXIX. 

Diseases of the Ductless Glands. 

Page 
The Thymus; Enlargement of the Thymus; Status Lymphaticus ; Diseases 
of the Spleen ; Inflammation of the Spleen ; Chronic Passive Congestion of 
the Spleen ; Disorders of the Adrenals ; Addison's Disease ; Hodgkin's 
Disease (Lymphadenoma) ; Acute Adenitis; Chronic Adenitis; Exophthal- 
mic Goitre ; Achondroplasia ; Infantilism ; Cretinism 396 



SECTION X. 
General Diseases of Nutrition. 



CHAPTER XXX. 

Nutritional Disorders. 

Rachitis ; Congenital Rachitis ; Scorbutus ; Marasmus ; Diabetes Mellitus . . 412 

SECTION XI. 

Diseases of the Uropoietic System. 



CHAPTER XXXI. 

Diseases of the Urine and Kidneys. 

The Urine in Infancy ; Character of the Urine ; Formation of the Kidney ; 
Anuria ; Polyuria ; Diabetes Insipidus ; Renal Calculi ; Hematuria ; Hemo- 
globinuria ; Functional Albuminuria (Cyclic or Physiologic Albuminuria) ; 
Indianuria ; Acetonuria and Diacetonuria ; Congestion of the Kidney ; 
Chronic Congestion (Passive Hyperemia) of Kidney; Nephritis, Acute, 
Chronic ; Pyelitis ; Perinephritis ; Tumors of the Kidney ; Hydronephrosis ; 
Enuresis 425 

SECTION XII. 
Diseases of the Genital Organs and Bladder. 



CHAPTER XXXII. 

Diseases of the Genital Organs. 

Phimosis and Paraphimosis ; Balanitis ; Urethritis ; Vulvovaginitis, Mastur- 
bation ; Hydrocele ; Undescended Testicle ; Differential Diagnosis of 
Swellings in the Inguinal Region 447 



\\1 CONTENTS. 

CHAPTER XXXIII. 

Diseases of the Bladder. 

Page 
Cystitis: Vesical Spasm; Vesical Calculus 454 



SECTION XIII. 
Diseases oe the Nervous System. 



CHAPTER XXXIV. 

General Nervous Diseases. 

General Considerations ; Paralysis in General ; Characteristics of the Various 
Types; Convulsions; Chorea; Hysteria; Epilepsy; Headaches (Migraine) ; 
Insomnia ; Pavor Nocturnus ; Tetany ; Congenital Myotonia (Thomsen's 
Disease) ; Paramyoclonus Multiplex ; Angioneurotic Edema ; Tics . . . 456 



CHAPTER XXXV. 

Diseases of the Peripheral Nerves. 
Multiple Neuritis ; Diphtheritic Paralysis ; Facial Paralysis 476 

CHAPTER XXXVI. 

Diseases of the Spinal Cord. 

Myelitis; Multiple Sclerosis; Hereditary Ataxia (Friedrich's Disease); Pri- 
mary Myopathies 480 

CHAPTER XXXVII. 

Diseases of the Brain. 

Meningitis; Encephalitis; Abscess of the Brain; Tumors of the Brain; Cere- 
bral Palsies; Hydrocephalus; Microcephalus ; Idiocy; Imbecility; Feeble- 
mindedness: Mongolian Idiocy; Amaurotic Family Idiocy ; The Binet- 
BimoD Tests 488 



COXTEXTS. XV11 

SECTION XIV. 
Coxgexital Malformations axd Deformities. 



CHAPTER XXXVIII. 

Congenital Malformations and Deformities. 

Page 
Tongue Tie, Hare-lip ; Cleft-palate ; Branchial Cysts ; Malformations of the 
Esophagus ; Malformations of the Rectum and Anus ; Hypospadias ; 
Extrophy of the Bladder ; Congenital Dislocation of the Hip ; Congenital 
Absence of Bones ; Talipes ; Webbed Fingers and Toes ; Meningocele and 
Encephalocele ; Spina Bifida 505 



SECTION XV. 

The Commoxer Surgical Diseases. 



CHAPTER XXXIX. 

The Commoner Surgical Diseases. 

Anesthesia; Hernia; Circumcision; Appendicitis; Intussusception (Including 
Intestinal Obstruction) ; Peritonitis, Acute, Newly-born, Early Life, 
Pneumococcic ; Ascites ; Ischiorectal Abscess ; Rectal Polypus ; Fissure of 
the Anus ; Prolapse of the Anus and Rectum ; Malignant Tumors in 
Childhood ' 516 



SECTION XVI. 

Diseases of the Ear and Eye. 



CHAPTER XL. 

Diseases of the Ear 

General Consideration ; Otoscopy ; Otitis ; Mastoiditis ; Infective Cerebral 

Sinus Thrombosis 531 

CHAPTER XLI. 

The Commoner Diseases of the Eye. 

Foreign Bodies; Blepharitis; Conjunctivitis, Diphtheritic, Chronic, Granular; 
Chalazion ; Strabismus ; Keratitis ; The Diagnostic Significance of Ocular 
Affections; Diagnostic Hints 536 



Will 



CONTENTS. 

SECTION XVII. 

Diseases of the Skin. 



CHAPTER XLIL 

Diseases of the Skin 

Page 
Ichthyosis: Xevi ; Dermatitis Exfoliativa Neonatorum (Hitter's Disease); 
Pemphigus Neonatorum; Impetigo Contagiosa; Seborrhea Capitis; 
Erythema Multiforme; Acute Exfoliative Dermatitis; Eczema, Acute, 
Subacute, Chronic; Psoriasis; Miliaria; Urticaria; Furunculosis ; Herpes 
Zoster ; Pellagra 541 

CHAPTER XLIII. 

Parasitic Skin Diseases. 

Pediculosis ; Scabies ; Tinea Tonsurans ; Tinea Favosa ; Alopecia Areata ; Ivy 

Poisoning 554 

INDEX 559 



DISEASES OF CHILDREN 



SECTION I. 
THE NEWLY-BORN. 



CHAPTEE I. 
THE MANAGEMENT AND CARE OF PREMATURE INFANTS. 

When a premature infant is born it is suddenly deprived of a very 
important organ, namely, the placenta, which has a selective action for the 
developing fetus. Three and sometimes four factors mitigate strongly 
against its extrauterine existence. These factors are in the order of their 
importance: (1) Undeveloped heat and respiratory centers; (2) increased 
susceptibility to infection; (3) patent umbilical vessels with a tendency to 
putrefaction; and (4) sometimes possible congenital disease from its 
progenitors. 

The temperature of a premature babe at the time of birth varies from 
98.6° to 100° F. It is often suddenly introduced into, and examined in 
a room temperature of 7-4° F. ; that is, with a variation of 24° or 26° F. 
A subnormal temperature undoubtedly often results, from which the child's 
undeveloped heat centers fail to assist it. A lowered temperature, then, is 
the first evil to combat. 

More than one-half of all deaths under four weeks are attributable to 
prematurity. We believe that many premature infants that help to swell 
the mortality statistics may be saved by timely and appropriate directions 
from their medical attendants. More viable under-term children are born 
now than formerly, owing to better methods at the time of birth and to such 
surgical measures as Cesarean section. The records of those born and 
reared in a maternity hospital show a high percentage saved ; but these 
cases had never been exposed to chilling and transportation and had the 
advantage of woman's milk as a pabulum. Our maternity hospitals have 
no facilities for caring for outside cases, and these are finally sent after a 
variable time to an institution which has an incubator. The natural solu- 
tion would seem to be incubator life, and this apparatus will maintain the 
body heat, if properly managed, at 90° F.. but it will also necessitate that 
the babe respire this superheated air, often vitiated and liable to germ 

1 



a DISEASES OF CHILDREN. 

ron (a m ination. Constant and eternal vigilance is required to keep the 
apparatus — even the best obtainable — in proper working order. If the 
temperature rises suddenly, a heat stroke results, and if the gas pressure 
falls or the wind changes, a subnormal temperature may follow. The pre- 
mature infant delivered at home should therefore be placed in a padded 
basket or erib (see Fig. 1) and surrounded with hot-water bottles, or kept 
warm with an electric heater. The room must be quiet and a sunny one; 
it should be kepi at 78° to 80° F., preferably heated and ventilated by an 
open li replace. The supply of fresh air should be constant. If unavoidably 
the infant's temperature has fallen to subnormal, a warm bath and gentle 
friction are indicated before supplying the swaddling blankets made of 
cotton which are to serve as clothes. The importance of conserving this 
body heat may be emphasized by the statistics of Budin in France. Ninety 
per cent, of the premature infants died who had a temperature between 
90° and 92° F. 




V\c. 1. Padded basket-crib suitable for premature infants replacing an incubator. 



It is a Bignificanl fact that the great majority of cases brought to us 
for incubator life al the hospital have a subnormal temperature. 

The weighl and length must next be considered in its relation to 
viability and to feeding. If the weight is below 24 pounds, the premature 
are rarely Baved, while those with birth weights between 2J and 5 pounds 
arc to be regarded as congenially feeble. The length of time in utero is, 
however, of greater importance than the birth weight in establishing the 
prognosis. Moore saved a premature infant born at the sixth month of 
gestation which was nine inches long and weighed one and one-half pounds 



THE MANAGEMENT AND CARE OF PREMATURE INFANTS. 



ful consideration. 



1 



\- 



7/ 



L 



Fig. 2.— 
feeder for p 
ture infants. 



^lU 



(this babe weighed 19 pounds at the end of fifteen months). Therefore, if 
the child is born alive, it should be given every elr.mce to live. The 
obstetrician should immediately place the babe in a warmed blanket or in 
warm cotton wool and have hot bottles close to its body and beneath it. 
Swaddling clothes are later used. 

The next problem will be that of nutrition. An 
undeveloped digestive tract with a minimum amount 
of secretions and an over-active liver will demand care- 
The breast milk of a woman whose 
child is about ten days old is the ideal 
food. This should be diluted with 
water three times in the beginning, and 
later twice, and finally undiluted breast 
milk is allowed, especially if the in- 
fant is strong enough to suck. The 
quantity given should approximate one- 
fifth of the baby's weight, if it is above 
four and a half pounds ; but very small 
amounts, one dram every hour, should 
be ordered for the first few days, and 
very gradually increased. 

The mothers own milk should be 
pumped, massaged, or nursed out by 
another stronger child, but should not 
be used for a week or ten days, as the 
colostrum at this period of gestation. 
as shown by Adriance, is too rich in 
proteins. A wet nurse for a short 
period or a small amount of breast 
milk (often one ounce will be helpful 
for twenty-four hours) should be other- 
wise obtained. If this is impossible, 
a -t per cent, dextri-maltose solution is 
fed for a few days. Plain whey made 
as directed on page 141 may be now 
fed in 1 t<> 2 dram doses every hour, 
depending upon the weight of the child. 
r I Tiis is gradually increased to 1 oz. 
every li/> to 2 hours. Tf the prema- 
ture infant is one born nearly at term, with it- power- of suckling well 
developed. y 2 per cent, fat is added to the whey. Attention musl again 



I'k.. ."». — Home- 
made feeder. 



4 DISEASES OF CHILDREN. 

be called to the great value of even a small quantity of breast milk, to 
assist in the digestion of the artificial feeding. Later, as the weight 
increases, skimmed milk mixtures made from the mixed remaining milk, 
after removing top 4 oz., and diluted 5 times with cold boiled water, to 
which 4 per cent, of sugar has been added, will usually be found to agree. 

Peptonization is indicated if the stools show feeble digestion. The 
weaker infants are fed with a dropper, while those capable of making suck- 
ing efforts are fed with a modified Breck feeder. This can be made from 
a piece of glass tubing with dropper nipples applied, the one being perforated 
by three small holes (see Figs. 2 and 3). Gavage is dangerous, for we 
have found milk in the trachea and bronchi of premature infants at autopsy 
which reached there via the tube. The medical attendant must not be 
discouraged to note a falling off in weight for some time. It is sometimes 
three to four weeks before the birth weight is regained. The nurse must 
be ever watchful for attacks of cyanosis, which must be combated with two- 
to five-drop doses of diluted brandy, or camphor, gr. ^, in sterile olive oil 
hypodermatically. The icterus, which is not uncommon and which is 
usually associated with constipation, often produces fatal results. It is best 
treated with one- to two-twentieths of calomel. 

Daily inunctions of liquid petrolatum (albolin) are given in lieu of 
baths for cleanliness after the usual diapering. After the first year these 
premature infants are not necessarily weak and puny, but on the contrary 
are often indistinguishable from the full-term infant. The prognosis, 
however, should always be considered as unfavorable, as the undeveloped 
digestive tract, the possibility of sepsis, and the defects in the heart all 
mitigate against its existence. The importance, however, of obtaining 
breast milk cannot be overestimated, for it is almost impossible to raise them 
without its help. Our experience, which includes over one hundred pre- 
mature cases, leads us to advocate the open method of treating premature 
infants to the use of the incubator, and we have tried all kinds. If an 
incubator is iised, only the type having connection with the outside air 
should be employed, as these infants are exceedingly susceptible to a lack 
of fresh air. 



CHAPTER II. 
INJURIES DURING BIRTH. 

Deformity of Head. 

A certain pointing toward the occiput and elongation of the head are 
noted in most labors. This may be extreme in cases where a long or diffi- 
cult labor has resulted in excessive moulding of the presenting part. For- 
tunately, little damage is done by this distortion and the head usually takes 
on its natural shape in a few days. 

Caput Succedaneum. 

The swelling on the presenting part of the head resulting from pres- 
sure is known as caput succedaneum. It consists of transuded serum and 
extravasated blood located between the scalp and pericranium in the loose 
connective tissue of this part. It has a soft, boggy feeling. Prolonged or 
difficult labors produce this effusion from pressure on the portion of the 
head that presents. Xo special treatment is required, as the absorbents of 
the connective tissue will cause its disappearance within a day or so. 

Cephalhematoma. 

Cephalhematoma is an effusion of blood between the bone and the 
periosteum covering it. It usually appears within one to three days after 
birth. Its seat may be any portion of the cranial vault. Most commonly 
it occurs in the parietal region, sometimes over the temporal or occipital 
bones. The overlying integument presents no discoloration. A bonv ring 
is soon developed around the base from the secretion of the periosteum. 
The effusion is, in most cases, limited by a suture. The effused blood, as a 
rule, undergoes absorption within the first three months of life. In rare 
cases suppuration ensues, and even caries of the subjacent bone may occur. 
The fact that the tumor does not communicate with the brain cavity, which 
fact can usually be readily made out by palpation, serves to distinguish this 
affection from encephalocele. To differentiate caput succedaneum and 
cephalhematoma it may be borne in mind that while the former is non- 
fluctuating and disappears in a few flays, the latter is soft and fluctuating, 
presenting a marginal ridge, in the center of which the sknll is felt, and 
disappears in a few months. 

Treatment. — In most cases no treatment is called for. Should the 
tumor grow it may be strapped with adhesive plaster, the head first being 

5 



6 DISEASES OF CHILDREN. 

shaved. Incision, while generally condemned, has been practised with 
success. It offers the advantage of immediate relief and leaves no per- 
manent deformity. The effused blood can usually be removed through a 
small opening. A firm compress is worn for several days to prevent refilling. 
It is needless to say that the strictest asepsis must be observed. If suppura- 
tion occurs the usual surgical treatment of abscess must be carried out. 

Injuries to Bone and Muscle. 

(a) Boxe. — The soft and partially developed condition of infantile 
bone renders it liable to injury if subjected to much mechanical violence 
during delivery. The cranial bones are especially liable to indentation and 
fracture when the forceps is employed, yet such accidents may occur in 
spontaneous labor. Fracture of the cranial bones is most frequent in the 
parietals. When the brain is not injured the fracture is not apt to result 
seriously. Rupture of intracranial blood-vessels may lead to fatal hemor- 
rhage. Simple indentations apparently cause little if any damage to the 
brain structures. Gentle efforts at reduction may be attempted, and thus 
the normal shape be restored. Fracture of the inferior maxillary bone may 
result from traction with the fingers in unskillful delivery of the after-com- 
ing head in breech presentations. Injuries may be inflicted upon the 
vertebra 3 or the spinal cord, with resulting paraplegia, and they are almost 
invariably fatal. Fracture of the humerus not uncommonly occurs in forci- 
ble delivery of the arm in breech births, or separation of the epiphysis from 
the shaft of the bone may take place. Fracture of the clavicle usually 
results from violent use of the fingers in extracting the after-coming head. 
The femur may be fractured from misdirected traction with fingers or fillet 
in breech delivery. 

(b) Muscle. — Hematoma of the sternocleidomastoid muscle may 
result from artificial interference in breech extractions. A hard tumor 
about the size of a pigeon's egg may be seen developing in this muscle, 
usually on its anterior border. It is noticed between the ages of one and 
six weeks, and usually disappears by absorption in a month or so. The 
muscle fibers are sometimes torn. Hematoma of the sternocleidomastoid 
may lead to contracture of the injured muscle and torticollis. As a rule, 
the blood is spontaneously absorbed in a few weeks. 

Birth Palsies. 

Injuries to the nerves during birth may be central or peripheral. The 
latter are fortunately the most common, and the usual tvpes are facial 
and upper-arm paralysi>. 



INJURIES DURING BIRTH. 7 

(a) Facial Paralysis. — Pressure upon the seventh or facial nerve 
at the stylomastoid foramen by the blades of the forceps is usually respon- 
sible for facial paralysis. The affection is, in most cases, unilateral, and 
will not be noticed when the infant is at rest. When nursing or crying, 
the palsy of the affected side is apparent. Eecovery usually takes place 
spontaneously in a few weeks. If the paralysis does not disappear promptly, 
faradism may be employed. In rare cases the palsy is permanent. 

(b) Upper-arm Paralysis (Erb's or Duchenne's Paralysis). — 
The next most frequent peripheral palsy is seen in the arm. Various 
conditions during birth may produce compression and injury of the nerves 
about the shoulder, such as severe pressure of the obstetrician's finger or 
the blunt hook in the axilla, hematoma of the sternocleidomastoid, or frac- 




Fig. 4. — Erb's paralysis — right arm affected. 



ture of the humerus with displacement of the fragments. The greatest 
number of upper-arm paralyses, generally known as Erb's or Duchenne's 
paralysis, occur after breech deliveries. The injury usually results from 
traction made upon the shoulder in the delivery of the head, or in bringing 
down the arm when it is found above the head or upon the head in vertex 
deliveries, and is due, as a rule, to stretching of the fifth, sixth, and seventh 
cervical nerves. Dragging the head or the trunk strongly to one side is 
usually responsible for the excessive traction upon the nerve trunks of the 
injured side. The deltoid, biceps, brachialis anticus. and supinator longus 
are the muscles oftenest affected. In mild cases the paralysis may not be 
noticed for some weeks, while in severe ones it will usually be apparent 
at once. 



8 DISEASES OF CHILDREN. 

Diagnosis. — The position of the arm is characteristic. It hangs help- 
less at the side and is rotated inward. As the triceps is not affected, the 
child can extend the forearm, but cannot flex it. After a few weeks the 
affected muscles show more or less atrophy, but the child will generally 
begin to use the forearm. The diagnosis of Erb's paralysis is not, as a rule, 
difficult when seen during the first year. The peculiar position of the arm 
and the group of muscles involved are rarely met with in any other affection 
at this early age. 

Prognosis. — The prognosis will blepend upon the severity of the 
symptoms and the time when the treatment is begun. Spontaneous recov- 
ery takes place in some cases within two or three months. If there is but 
little improvement after this length of time, spontaneous recovery is not to 
be expected, and the case demands active treatment. In some cases partial 
paralysis may remain for several years or be permanent. 

Treatment should be begun early, and should consist in massage, 
passive motions of the joint and the persistent use of electricity. If the 
muscles react to the faradic current, it may be used; but if not, the gal- 
vanic current must be employed. The treatment must be continued for 
several months, or until recovery is nearly complete. The foregoing 
treatment applies also in facial paralysis. 

Central Paralysis. — Meningeal apoplexy, followed by various 
paralyses, is one of the untoward results of prolonged and difficult labor. 
This is more apt to occur with the first-born child owing to the unyielding 
character of the maternal parts. While hemiplegia is the rule, from the 
distribution of the hemorrhage over the surface of one side of the brain, 
there may be less diffused local hemorrhages resulting in paralysis of the 
face or of one arm or leg. In eleven autopsies following this injury, as 
reported by Dr. McNutt, the hemorrhage was principally at the base of the 
brain in the vertex presentation, whereas it was largely on the convexity in 
the breech presentations. It has been supposed that the use of forceps is 
largely responsible for this accident, and the rough and careless use 'of 
instruments is doubtless a competent cause. The writer believes, however, 
that too long delay in the application of the forceps when the head is being, 
subjected to prolonged pressure is oftener responsible for this unfortunate 
accident. The careless use of drugs before delivery, by inducing a tetanic 
contraction of the uterus, also favors congestion of the fetal brain. 

Symptoms and Prognosis. — The symptoms induced by meningeal 
extravasation depend, of course, upon the seat and extent of the effusion. 
The extravasation is frequently located over the motor convolutions, and if 
not extensive the hemiplegia may disappear with the absorption of the blood. 



INJURIES DURING BIRTH. 9 

If more extensive, however, the infant may be stillborn or, if living, it may 
soon die from asphyxia or in a comatose condition. The voluntary muscles 
in such, cases may be in a spastic condition, or more rarely, in a state of 
complete relaxation. The respiration is more apt to be depressed and 
irregular than the pulse. Convulsions may occur shortly after birth, fol- 
lowed by coma. If death does not ensue the prognosis for the extremities 
affected is good, as the paralysis gradually improves, often undergoing com- 
plete recovery. The brain, however, may be irreparably injured, as shown 
by subsequent epilepsy or even by various degrees of idiocy. 

Treatment. — The treatment must be preventive. This consists in 
avoiding as much as possible prolonged pressure upon the fetal head, in a 
careful use of the forceps, and in seeing that the infant cries immediately 
after birth, thus being assured that the lungs are inflating. It is of great 
importance that the transition from the fetal to the post-natal circulation 
should at once take place at birth, as otherwise great damage may be done, 
particularly to the brain; the vessels here are fragile and easily raptured. 
If the infant cries the expanding lungs draw off the excess of blood that 
may do damage elsewhere. The physician should give his first attention 
to the infant until this happens, as a short period of asphyxia may do 
incalculable harm. If the lungs do not act, it is well to let the cord bleed 
to the extent of a few drams to prevent feevere congestion of other vital 
organs. 

Asphyxia. 

The accidents during labor that induce asphyxia are : sudden death 
of the mother, constant pressure upon the umbilical cord, severe compression 
of any part of the fetal body, especially the head, as noted above, and more 
or less complete detachment of the placenta. In consequence of the air- 
hunger induced by these conditions, a vigorous infant may by inspiratory 
suction take in secretions of the birth-canal, which may cause suffocation 
after birth or induce pneumonia later. Very feeble infants may fail to 
establish respiratory movements after birth, owing to weak or defective 
muscles and nerves. In partial asphyxia there is congestion and suffusion 
of the skin, with blueness of the mucous membranes, full pulse, and mod- 
erate action of the reflexes. As the symptoms of carbon-dioxid poisoning 
become more marked, the pulse grows feebler, the skin paler, and the mucous 
membranes assume a grayish-blue color. The reflexes are likewise lost. 
The prognosis in the latter condition is exceedingly bad. In the milder 
degrees of birth-asphyxia recovery usually ensues. 

The Preventive Treatment consists in measures addressed to the 
acceleration of tedious labors and the prevention of prolonged pressure upon 



10 DISEASES OF CHILDREN. 

the fetal parts, especially the head. During descent of the head malposi- 
tions of the cord, especially prolapse, or winding tightly around the neck, 
must be looked for and, if possible, corrected. One of the possible causes of 
asphyxia will be removed if as soon as the head is born it is so turned that 
the face shall not lie in a pool of blood and liquor amnii. At the same 
time the mouth and fauces can hastily be cleaned of mucus with a moist rag 
drawn over the finger or by means of a soft rubber tube with a rubber bulb 
attached. In moderate degrees of asphyxia the stimulus of the cool external 
air and allowing a dram or two of blood to escape by the cord will be suffi- 
cient. Should this not suffice the chest may be sprinkled with cold water 
to stimulate the reflexes, while the infant is held suspended by the feet for 
the purpose of allowing mucus to gravitate from the air-passages. The 
child may be plunged alternately into hot and cold water. The hot water 
should have a temperature not exceeding 105° F. When these external 
stimuli fail to excite respiratory movements, resort must be had to artificial 
respiration. 

The child's pharynx should first be cleared of mucus and other liquid 
material that may have been drawn into it by premature efforts at respira- 
tion. The simplest and most effectual method of inflating the lungs is by 
direct insufflation — the mouth-to-mouth method. In hospitals the lung- 
motor regulated to suit the respiratory capacity of the infant is used. 

Direct Insufflation. — The child is placed upon its back with the head 
extended by means of a small pillow or roll of clothing placed under its 
neck; the mouth is well cleansed and a towel or handkerchief is spread 
over the face. With one hand closing the nose, and with the other making 
pressure upon the epigastrium, to prevent the inflation of the stomach, the 
physician forces air from his own gently into the child's mouth and inflates 
the lungs. The air is expelled by gentle pressure upon its chest, and the 
process then repeated. When properly performed, this method is safer 
than passing a catheter or other instrument into the trachea, as is some- 
times practised. Care should be taken lest injury be done to the air-cells 
by too forcible expansion. 

Various methods of artificial respiration may be employed. Schultze's 
method is most commonly employed. The operator holds the infant sus- 
pended, face to the front, his index-fingers being hooked in the axillae, the 
thumbs resting on the front of the chest and the fingers upon the infant's 
back. The lower portion of the child's body is now swung outward, 
upward, and finally toward the operator's face, inverting the position. 
Care should be taken that the trunk is most strongly flexed in the lumbar 
region. In thi? position the thorax is compressed — expiration. The child's 



INJURIES DURING BIRTH. 11 

lower extremities are now swung outward away from the operator's body 
and downward till the child hangs suspended by its axillae in the position 
first described. In this position of the child, hanging by its upper extrem- 
ities, the abdominal contents fall and the diaphragm sinks — inspiration. 
To assist the respiratory movements the pressure of the operator's thumb 
is relaxed during inspiration and increased during expiration. This 
method is not to be recommended in feeble children. 

Laborde's method is easy to apply in the case of very feeble infants. 
It consists in making rhythmical traction upon the tongue, eight to ten 
times to the minute. 

After the respirations have been started, the infant must be watched to 
see that they continue. It may be advisable in some cases to administer 
hypodermatically ten to twenty drops of whiskey combined with 1 minim 
of the tincture of belladonna or 1/200 grain of strychnin. In most cases 
it will be necessary after resuscitation to apply heat by a hot-water bag 
or other means. In asphyxia pallida a rectal injection of water at a 
temperature of 110° F. is of marked service. 

Congenital Atelectasis. 

Closely allied to asphyxia, and often associated with it, is a persistence 
of the fetal condition of the lungs, either of one or both in whole or in part. 
It is clue to failure of the infant to completely inflate the lungs, and may 
persist for a considerable time. Sometimes it results in death, even after 
respiration has apparently been fully established. 

This is more apt to involve the lower lobes than the upper ones. It is 
frequently seen in premature infants with feeble respiration. The cause 
may also be injury to the brain from pressure. The symptoms are those of 
deficient respiratory action, such as pallor, feeble cry, and poor circulation, 
with very little expansion of the chest-walls over the affected area. Deep 
inspiration may be encouraged by artificial respiration, and the vitality 
conserved by the external application of heat and the judicious administra- 
tion of nourishment and stimulants. 

Fetal Death. 
Death may take place at or before birth, which must sometimes be differ- 
entiated from asphyxia. In the former the heart pulsations cannot be felt and 
respirations and reflexes are absent. In the latter the heart is pulsating, reflexes 
are present, and there may be feeble attempts at respiration. We should not 
refrain from efforts at resuscitation because the heart-sounds are absent or no 
pulsations can be felt in the precordial region. The distinction between a dead- 
born and a still-born infant can usually be made by the rapid fall of rectal 
temperature in the former to ten or fifteen decrees below normal and by the 
widely dilated condition of the pupils in the dead-born. In the still-born, artificial 
respiration may be employed, and the hypodermatic injection of a few drops of 
whisky and gr. 1/200 of sulphate of strychnin may be given. 



CHAPTER III. 
DISEASES OF THE NEWLY-BORN. 

Acute Infectious Disease. 

While the newly-born infant seems to bear a sort of natural immunity 
to the common infectious diseases of childhood, it is possible for an infant 
to be infected through the placenta before birth or by the usual methods 
soon after birth. While the symptoms of measles, pertussis, pneumonia, 
scarlatina, or influenza are largely the same as when seen later on, the 
prognosis in the newly-born is bad. 

Sepsis of the Newly-born. 

An infection induced by pus-forming organisms such as the strepto- 
coccus pyogenes and the staphylococcus pyogenes aureus and albus may 
be seen in the newly-born. The umbilicus is the most vulnerable spot for 
the entrance of septic poisons during or shortly after birth. Upon ligation 
of the cord the blood that remains in the umbilical veins forms small 
thrombi that should gradually harden and in time become calcined, forming 
a fibrous cord in the same manner as in the ductus arteriosus and ductus 
venosus. In these latter structures the formation of thrombi is never 
accompanied with grave consequences, since their internal situation prevents 
the access of infectious agents. Pyogenic organisms, however, can readily 
gain access to the umbilical vein and give rise to umbilical phlebitis and 
septicemia. 

There is a constant alteration after birth in the blood-pressure in the 
umbilical vein, due to the action of the heart and lungs, by which a sort of 
flux and reflux is produced. This favors infection of the system when the 
contents of this vein become septic. 

This grave accident is liable to occur when the mother is in a septic 
condition. The poison may be produced by the same agents that have 
caused the puerperal fever. In these cases of sepsis there is a puriform or 
yellow softening of the thrombi that fill the umbilical vein. The softened 
matter consists of pus-corpuscles and finely granular matter containing 
micrococci. This sets up an inflammation not only in the vessel itself, but 
also in the surrounding tissues. Infective emboli may be carried to various 
parts of the body. As the micrococci enter the umbilical vein from the 
umbilical fossa, owing to the perviousness of this vessel, the structures near 
at hand, especially the liver, bear the first brunt of the septic inflammation. 

12 



DISEASES OF THE NEWLY-BORN. 13 

The latter organ is usually found much diseased or degenerated. There 
is jaundice, with constant elevation of temperature and other symptoms of 
general septic infection. If the infant lives long enough peritonitis will 
probably develop, and sometimes empyema, pleuropneumonia or even men- 
ingitis. In all cases evidence of severe illness and prostration are present. 
Cutaneous, mucous, or visceral hemorrhages may supervene at any time. 
The abdomen is generally swollen and tender, and dirty -looking pus may 
be seen oozing from the navel; slight pressure about the umbilicus will 
often cause pus to exude if it is not otherwise apparent. The fecal dis- 
charges may be of natural appearance, but the urine is usually highly 
colored. The infant refuses nourishment, and there may be vomiting of 
greenish matter. Severe nervous symptoms, such as convulsions or coma, 
supervene before death. While the umbilicus is the most common seat of 
septic infection, any sore or abrasion elsewhere may afford entrance to 
germs. Erysipelatous eruptions on the abdomen, chest, or other parts, are 
the most frequent manifestations of such infection. 

Multiple joint inflammation and suppuration may appear as evidences 
of a general pyemia, and a few cases of osteomyelitis have been reported. 

Treatment. — The prophylactic treatment of sepsis consists in the 
careful antiseptic management of labor and proper attention and cleanli- 
ness in reference to the navel. Localized sepsis may be combated by the 
topical use of peroxid of hydrogen, bichlorid of mercury solution, or other 
strong antiseptic agents. 

The remedial treatment of systematic infection consists in full stimu- 
lation and general support and the judicious use of external refrigerant 
measures. In the latter condition, however, treatment is generally futile. 
Empyema, pleuropneumonia, erysipelas and any other local effect of 
infection must be treated symptomatic-ally. 

Umbilical Hemorrhage. 

Hemorrhage may take place from the stump of the cord shortly after birth 
from insecure ligation, from shrinkage of the funis, or from slipping of the liga- 
ture. Laceration of the cord between the abdomen and the ligature may also 
be responsible for hemorrhage. Secondary hemorrhage, usually between the fifth 
and fifteenth days, may occur, even though the cord has been securely li gated 
and properly watched. The trouble may be due to changes in the walls of the 
minute blood-vessels, allowing transudation, or to imperfect coagulability of the 
blood. In the latter case the hypogastric- artery and the umbilical artery and 
vein have not been tightly occluded by the usual fibrinous plug. The hemorrhage 
is accounted for by syphilis, jaundice, hemophilia, or by depraved health on the 
part of the parents. 

Treatment. — The great majority of cases are fatal from the impossibility of 
controlling the hemorrhage. In the milder ones a compress of gauze tightly 
applied with adhesive strips may be sufficient. 



u 



DISEASES OE CHILDKEX. 



Adrenalin (1/1000) may also be used to moisten the compress. In the most 
obstinate cases it may be necessary to transfix the umbilicus by two needles 
placed at right angles with a figure-of-eight ligature placed tightly around them. 

Umbilical Vegetations. 
Fungous granulations at times appear, arising from the floor of the umbilical 
fossa, shortly after the falling of the cord. They may attain the size of a pea, 
and they usually exude a bloody serum, which may induce excoriations in the 
surrounding skin. The granulations may gradually atrophy after weeks or 
months of sluggish existence. The constant moisture and discharge is, however, 
a source of irritation, and it is best to destroy the growths. This can be accom- 
plished by repeated cauterization with the solid stick of nitrate of silver or, better 
still, by passing a ligature around the base of the mass and amputating the 
exuberant granulations with scissors. A dry dressing of boric acid or subgallate 
of bismuth may then be applied. 



Umbilical Hernia. 

There is a tendency, especially on the part of badly-nourished in- 
fants, for the gut to protrude a little at the umbilicus. It is hence 
desirable to keep a firm abdominal binder in place for the first two 

or three months. After this 
time if a protrusion persists, 
the hernia may be retained 
by long strips of adhesive 
plaster. It may be neces- 
sary to keep up this support 
for several months. The 
dressing may be examined 
and changed every few 
weeks to be sure the pres- 
sure stays in the right place. 
The skin must be kept 
scrupulously clean and fre- 
quently dusted with powder. 
In older infants, an abdom- 
inal truss may occasionally 
do good service. It is rare 
for this form of umbilical 
hernia to last through child- 
hood. In exceptional cases 
when the rupture increases 
rapidly in size operative 

V\c. 5.— Adhesive plaster dressing for um- interference may be consid- 

bilical hernia, made with two pieces over- -. 

lapping. (PiseJc's method.) ered. 




DISEASES OF THE NEWLY-BORN. 15 

Epidemic Hemoglobinuria. 

(W nickel's Disease.) 
This form of hemoglobinuria is very rarely seen in the newly-born and then 
usually in institutions. It begins a few days after birth in healthy infants with 
constitutional symptoms of depression shown by a weak rapid pulse and general 
asthenia. An icterus soon develops that becomes very marked and is noted over 
the whole body. The urine is soon lessened in amount, contains traces of albumin 
and hemoglobin in large amounts. Casts are occasionally also found. The color 
of the urine may be dark or smoky. The disease progresses rapidly, often termi- 
nating in one or two days. There may be marked cyanosis with convulsions or 
coma before the close of life. The disease is evidently an outcome of some sort 
of infection, but the microbe has not yet been isolated. Treatment does not seem 
to be of much avail. 

Fatty Degeneration of the Newly-born. 
(Buhl's Disease.) 
This is a very rare disease that acts like some form of pyogenic infection. 
It is characterized by fatty degeneration of the heart, liver, and kidneys with 
hemorrhages from any of the mucous membranes or into the various serous cavi- 
ties or viscera. The spleen and liver are both usually enlarged. The disease is 
accompanied by great prostration and may last one or two weeks. Icterus may 
be present. The treatment is supporting and symptomatic, but not able to save 
life. 

Icterus Neonatorum. 

This is a common affection of the newly-born. Two distinct varieties 
are recognized, differing widely in cause and prognosis and known as the 
mild and grave forms. 

(a) Mild Forae. — - Two divergent theories have been advanced to 
account for this form. The first considers the jaundice to be purely 
hematic; the second theory regards it as hepatic in origin. Bile is first 
formed in the liver and then carried into the circulation, the resorption 
being due either to congestion or to edema of the hepatic tissue. It seems 
highly probable that both these theories may apply in different instances, 
and doubtless many cases of icterus neonatorum are to be satisfactorily 
explained only by taking into consideration a morbid condition of both the 
blood and the liver, thus combining the hematic and hepatic theories. 

The intense congestion of the skin observed during the first few hours 
of life often produces a yellowish coloration that cannot be considered 
jaundice. It is of the same nature as the discoloration of the skin follow- 
ing an ordinary cutaneous bruise. The yellow tint is. at first seen only on 
deep pressure, but as the erythema fades the yellowness increases. The 
conjunctivae are not colored, and the urine appears normal. This yellowness 
is usually first noticed on the second day, and may continue a few days 
or a week. 

The term "true icterus" can be applied only to tho.^e ca?e> in which 
the yellow discoloration of the >kin is caused by a staining by the bile pier- 



1G DISEASES OF CHILDREN. 

ments. This more often occurs in cases of prolonged or difficult labor, in 
children born asphyxiated or before term, and in generally feeble infants. 
It is very frequently seen in foundling asylums. It may appear as early 
as a few hours after birth, but usually is not marked until the second or 
third day. In very mild cases the yellow color may appear only on the 
face, chest, and back, the conjunctivae being but faintly tinted and the urine 
and feces normal in appearance. In severer forms the urine may be high 
colored enough to stain the linen, and the jaundiced hue may extend to the 
arms and abdomen. Some infants present a yellowish discoloration of the 
whole body, with typical clay-colored stools. In most cases the jaundice 
has disappeared by the eighth or tenth day. It may persist for several 
weeks. In rare cases, after having much diminished, it reappears with 
renewed intensity. K"o matter how extensive this form of jaundice may be, 
it causes very little constitutional disturbance. The liver may be slightly 
enlarged, and occasionally there are symptoms of intestinal indigestion. A 
few small doses of calomel or mercury with chalk will be all the medication 
required. 

(6) Grave Form. — This form is fortunately rare, and may be pro- 
duced by several different conditions. Defects in the bile-ducts will first 
be mentioned as among the commonest causes. In some cases all the 
large bile-ducts have been absent; in others the ductus communis chole- 
dochus has been narrowed, obliterated, or entirely absent. Sometimes a 
fibrous cord has been found in place of the gall-duct. The cystic duct has 
been absent and the gall-bladder in a rudimentary condition. Accompany- 
ing an obliteration of the gall-ducts cirrhosis is usually found in the liver, 
which will be more or less marked, according to the length of time the infant 
survives. The liver is generally enlarged. Jaundice that is due to 
obstruction or obliteration of the biliary passages may appear a few hours 
after birth and soon acquire a marked intensity. It often, however, does 
not appear for one or two weeks after birth. The yellowish discoloration 
of the skin may vary from day to day, at times being much more intense 
than others. The conjunctivae are yellow. The fecal discharges lose color 
and have an offensive odor, while the urine stains the napkin a yellow or 
greenish-brown. The spleen, as well as the liver, is usually enlarged, which 
partially accounts for the increase in size of the abdomen. Umbilical 
hemorrhage is a grave and not infrequent symptom in this form of jaundice. 
The bleeding is not sudden and profuse, but begins as an oozing shortly 
after the separation of the navel string. It is apt to commence at night. 
Death is alwavs hastened by this accident, and exhaustion from loss of blood 
i> added to that induced by indigestion and malassimilation. There may 



DISEASES OF THE NEWLY-BORN. 17 

also be a species of general purpura, bleeding taking place from the nose, 
mouth, or stomach. Infants may live for several months with impervious 
or defective bile-ducts, though death usually takes place earlier from failure 
of nutrition. 

Another form of grave icterus neonatorum is observed in connection 
with certain Inflammatory changes in the liver, usually taking the form of 
an interstitial hepatitis, with which may be conjoined inflammation of the 
biliary canals. This lesion is apt to be one of the results of congenital 
syphilis, as is likewise perihepatitis, which may cause a complete obliteration 
of the biliary passages. The latter form of inflammation often involves the 
connective tissue surrounding the common duct, the portal vein, and the 
hepatic artery on the under surface of the liver. These cases, however, may 
not always be of syphilitic origin. Perhaps the commonest manifestation 
of the grave form of icterus in the newly-born is seen in connection with 
septic poisoning that is generally accompanied with phlebitis. This has 
been noted under the head of sepsis. Later researches seem to prove that 
the bile itself may carry the infective agent. 

Tetanus Neonatorum. 

Although this disease is distributed through a wide geographical area, it is 
most apt to be found in filthy surroundings. Something beside filth, however, 
is necessary : there must be a specific cause. This consists in the tetanus bacillus, 
sometimes called Nicolaier's bacillus which produces tetanotoxin, a most virulent 
poison. It may exist in straw or dust from hay, which explains the fact that 
horses are subject to tetanus and that traumatic tetanus is often seen among 
laborers who are employed about farms and stables. 

The disease usually begins during the first ten days of life, and the onset 
is apt to be preceded by great fretfulness. Disinclination to nurse is soon fol- 
lowed by rigidity of the voluntary muscles, usually starting in the masseters. 
The rigidity increases, reaching its maximum in from twelve to twenty-four 
hours. The head is thrown back, and there is a general flexion of the extremities. 
One peculiarity of the disease is that while the toes are flexed the great toes are 
adducted. There may be some relaxation at times, especially during sleep, but 
there are constant exacerbations, provoked by any peripheral irritation. Respira- 
tion and circulation may be extremely embarrassed, and opisthotonus may bo 
present during these exacerbations. 

The temperature is irregular, but usually high. Toward the end the puise 
becomes rapid and feeble and death takes place from exhaustion. 

Treatment. — While the specific cause of the disease may gain entrance at 
any point of the body when the necessary lesion exists, the umbilical wound is 
undoubtedly the seat of infection in the sreat majority of cases of tetanus 
neonatorum : hence the utmost cleanliness must be observed in cutting the cord 
and in dressing it. The scissors, the ligature, and the entire management of the 
navel, cord, stump, and the umbilical wound must be rigidly aseptic. The excess 
of the gelatinous matter should lie stripped from the cord, and a dry, antiseptic 
dressing applied. Speedy mummification of the stump is the host safeguard 
against infection. Special care must be exercised in the umbilical dressings 
where the dwelling is easy of access to stable-yards containing horse-manure or 
loose earth. 



IS DISEASES OF CHILDREN. 

When the disease is once established it is almost invariably fatal. In cases 
of suppuration at the umbilicus, frequent cleansing with a solution of mercuric 
bichlorid of suitable strength should be employed. With reference to drugs, the 
two most valuable are potassium broinid, gr. iv every two to four hours, and 
chloral hydrate, gr. j every hour. The extract of calabar bean from 1/10 to 1/12 
grain may be given hypodermatically. While these are administered the infant 
must be given nourishment frequently, and stimulants should be freely employed. 
The difficulty of swallowing, however, is a source of embarrassment in satisfac- 
torily carrying out these measures. Nourishment may be given by the rectum or 
by a nasal tube. A tetanus antitoxin is now produced by several manufacturing 
chemists, but so far the experience reported in the serum treatment of tetanus 
neonatorum has been rather negative. 



Conjunctivitis. 

The conjunctival membrane in the newly-born is very sensitive, and 
frequently the seat of inflammation. A mild inflammation is often seen, 
unattended by swelling of the lids, the inner surface being reddened and 
covered with a slight viscous secretion. The eyes must be kept cleansed by 
frequent bathing or irrigation with a saturated solution of boric acid. A 
little sterile vaselin may be applied to the lids to prevent retention of the 
secretion by adhesion of their edges. 

Ophthalmia Neonatorum. 

This form of purulent conjunctivitis may be due to infection by the 
gonococcus in the severer cases or by various pyogenic cocci in the milder 
ones (Koch-Weeks bacillus). If the disease manifests itself by the second 
or third day, the infection probably took place during birth. When there is 
a delay of a week or more, however, the virus has probably been conveyed 
by careless attendants, by soiled fingers or other infected objects. The 
inflammation is of an intensely virulent type, involving both the ocular 
and palpebral conjunctivae. The sac is filled with a grayish mucopurulent 
secretion, and there is intense chemosis. The subconjunctival connective 
tissue and skin are much swollen, so that the eye can only with difficulty be 
opened. There are photophobia, pain in the eye, and rise of temperature. 
Unless the symptoms quickly subside, the eye is irreparably damaged by 
ulceration and partial destruction of the cornea. The inflammation begins 
in one eye, but soon attacks the other unless it is effectively protected. 
The diagnosis of the various forms may be made by culture or by direct 
smear ; the latter alone will disclose the gonococcal form ; a smear at least 
should be made in every case. 

The Prophylactic Treatment consists in employing antiseptic vaginal 
douches in the parturient woman when there is any mucopurulent discharge, 
and dropping two or three drops of a 2 per cent, solution of silver nitrate 



DISEASES OF THE SEWLY-BORN. 19 

into each eve of the infant immediately after birth, after the method 
proposed by Crede. 

Curative Treatment. — When the inflammation has actually begun 
the eye must be kept as free of pus as possible by constant washings with 
a saturated solution of boric acid. The swelled and puffy lids should have 
applied to them every few minutes gauze compresses that have been kept 
upon a cake of ice, and the pus must be removed even* hour or two. Con- 
stant cleansing and cooling of the surface will require the services of a care- 
ful nurse night and day. A 2 per cent, solution of nitrate of silver or of 
bichlorid of mercury, one or two grains to the pint, may be instilled 
between the lids every two or three hours, according to the severity of the 
case. As this affection so frequently results in blindness, it is well, if 
possible, to have the advice of an oculist. Protargol in 5 per cent, or 
argyrol 10 per cent, solution can be recommended as a substitute for nitrate 
of silver. It has the advantage of being less painful, and is equally efficient. 

If the disease is limited to one side an effort should be made to protect 
the sound eye from infection by applying a compress moistened with an 
antiseptic. The pupil must be dilated with sulphate of atropin if the 
cornea is attacked. 

Mastitis. 

The mammary glands of the new-born infant often secrete a milk-like sub- 
stance, which appears between the fourth and tenth days after birth. During 
this time there may be swelling of the glands, which gradually abates with the 
subsidence of the secretion until, usually by the twentieth day at the latest, both 
secretion and swelling have disappeared. In some cases, however, the glands may 
remain engorged and tender, and suppuration ensue. This implies infection, 
and is exceedingly rare when proper antiseptic precautions have been observed 
during and after labor. 

Treatment. — When there is simple swelling the parts may be cleansed with 
soap and water and bathed with a weak antiseptic solution, either of carbolic 
acid or bichlorid of mercury. Gentle support with absorbent cotton and a bandage 
will also be indicated. If, in spite of this, suppuration occurs, there will be 
rise of temperature and the local signs of abscess. Then early incision, under 
proper antiseptic precautions, constitutes the treatment. 

Sclerema Neonatorum. 

This rare condition consists of an induration of the skin and subcutaneous fat. 
The hardening may be present only in patches or involve all of the body. It may 
occur in the calves of the legs, in the thighs, buttocks or parts of the back. 
Sometimes the cheeks are principally involved. The skin may be tabulated or 
raised in ridges over the circumscribed patches. The part affected feels 
as hard as a board, and when the limbs are involved they become stiff and 
unyielding. In some cases the whole body becomes affected, then having 
almost the appearance and feeling of a cadaver. The skin feels hard and cold 
and does not pit on pressure as in edema. The capillary circulation is very 
sluggish which gives a bluish tint to the lips and nails. The coldness of the 
body is caused by a subnormal temperature. The pulse is feeble and the respira- 
tion slow or irregular. The prognosis is had where the hardening is at all 
extensive, the infant dying of exhaustion in a few days. In milder cases, where 



20 



DISEASES OF CHILDREN, 



only a few patches occur, such areas of induration may gradually disappear and 
recovery take place. The disease is apt to affect premature infants or those who 
are feeble and with low vitality from any cause. The treatment consists in con- 
serving animal heat and doing everything to promote the general nutrition. The 
cotton jacket may be employed and hot water bottles kept in the crib. Stimula- 
tion bv hvpodermics of camphor or caffein may be employed where there is much 
blueness from a feeble heart or atelectasis. 




Fio. 6. — Sclerema Neonatorum. 



Spontaneous Hemorrhages in the Newly-born. 

In addition to the accidental hemorrhages during the process of deliv- 
ery caused by pressure effects, we may occasionally have spontaneous hemor- 
rhages during the first week of life that are independent of birth. These 
hemorrhages may occur in connection with various forms of sepsis, with 
congenital syphilis or from unknown causes. A general predisposing cause 
doubtless exists in the great alteration in the circulation induced by the 
transition from fetal to extrauterine life, from the rapid changes taking 
place in the blood at this time, and the fragile state of the walls of the 
blood-vessels. The blood may ooze from the mucous membrane of the nose, 
mouth, gastrointestinal tract, umbilicus, or vagina. The skin may also be 
affected, especially at the occiput, along the back and wherever pressure is 



DISEASES OF THE NEWLY-BOKX. 



21 



apt to be exerted. There may likewise be small extravasations in the vari- 
ous viscera, but these are not usually recognized during life. The hemor- 
rhage takes the form of slow, continuous oozing and is not apt to last more 
than one or two days. While the actual loss of blood may not be great, a 
large number of the cases die from exhaustion, as losses of blood are not well 
tolerated at this time. The bleeding is apt to start from the intestinal tract, 
called melena neonatorum, when the infant may be restless or somnolent, 
with bloody stools, and occasionally vomits hemorrhagic masses. The umbil- 
icus may begin to show oozing a few days later and hematuria is sometimes 
noted. Where the hemorrhage is limited to the nose, congenital syphilis is 
probably the cause. While the etiology of some of these cases is obscure, 
the condition is different from hemophilia, and the hemorrhages usually 
stop spontaneously in a few davs. 




Fig. 7. — Flask for collection of blood serum. 



Unless immediate treatment is instituted the prognosis is bad, the 
infants succumbing to exhaustion. The treatment consists in trying to keep 
up the strength by careful feeding and stimulation and by employing 
adrenalin in connection with the bleeding surfaces when they can be reached. 
The recent work of Dr. John E. Welch, however, has yielded brilliant 
results. His treatment consists in the subcutaneous injection of normal 
human blood serum, 10 c.c. three times a day. and. in severe cases, every 
two hours, starting at the very beginning of the hemorrhage. The technic 
of collecting the blood is as follow? : 

The arm at the hend of the elbow should be made surgically clean. Iodine for this 

purpose is not very satisfactory, as it tends to conceal the faint blue coloring of the veins, 
making it difficult or impossible to find them. A muslin bandage or a piece of rubber 
tubing is drawn around the arm just above the elbow sufficiently tight to cut off the 



22 DISEASES OF CHILDREN. 

venous circulation but should not entirely obliterate the pulse. The most prominent 
vein in the forearm or at the bend of the elbow is chosen and a rather small sized 
aspirating needle connected to the previously sterilized apparatus quickly pushed into it, 
the point being opposed to the direction of the current. If the needle is in the lumen 
of the vessel there is a fairly rapid flow of blood. As soon as a flow of blood is established 
the constricting bandage is removed or loosened. 

The needle should be connected by means of a rubber tubing to a flask (Ehrlenmeyer 
flask). A partial vacuum may be obtained by suction through a second tube. The glass 
connection of the aspirating tube should be lightly plugged with cotton in order to prevent 
contamination. 

When the flask is filled with blood to the desired level it is stoppered with cotton and 
allowed to stand at room temperature for one or two hours ; and then is placed in an ice 
chest for ten or twelve hours. This allows the blood serum to separate from the clot. At 
the end of this time the serum is drawn up into sterile pipettes (the mouthpieces of 
which are stoppered with cotton) and is then run into large test-tubes for preservation. 
Each test-tube is to contain one dose. 

Injections of whole blood subcutaneously or transfusion of blood by 
the syringe cannla method (particularly homologous blood) are measures 
which have recently saved many of these infants' lives. The donor selected 
should be healthy and his blood tested for any hemolyzing action before 
the transfusion is made. 

Various diseases and affections that are often seen in the newly-born, 
but not confined to this period, will be discussed in their appropriate sec- 
tions. Among these may be noted tuberculous infection, congenital syphilis, 
thrush or sprue, colic and indigestion, edema and pemphigus. 



SECTION II. 
HYGIENE OF INFANCY. 



CHAPTER IV. 

HYGIENE OF INFANCY. 

After birth a careful inspection of the infant should be made to dis- 
cover any defects that may be present. The body should then be thoroughly 
oiled, and, if the infant is cold or gives evidence of poor vitality, it may be 
wrapped in cotton batting and put in a warm place for rest. Vigorous 
children may be bathed in water at 100° F. shortly after the oiling and 
then dressed. The first bath must always be given expeditiously in a warm 
room. A dry dressing is best for the cord, which, after a thorough powder- 
ing, may be Avrapped in sterile gauze. A daily sponging of the body with 
eastile soap and warm water will take the place of the bath until after the 
cord separates. A pad of sterile gauze may be applied over the umbilicus 
for several weeks and kept in position by the abdominal binder. 

The eyes can be cleansed with a saturated solution of boric acid or a 
2 per cent, solution of nitrate of silver where a purulent vaginal discharge 
has existed in the mother. The mouth may be gently wiped out with boiled 
water and a teaspoonful of tepid water given to swallow. 

Clothing. 

• 
The clothing consists of an abdominal binder of flannel, which, in a few 
months may be changed in vigorous infants to a knitted band with shoulder 
straps. The binder should not press so tightly as to retard the free expansion of 
the lungs in breathing. Next will come a shirt with a little extension below to 
which the diaper may be attached by pinning and then a flannel petticoat. Finally 
a dress of some light material will complete the raiment. Care must be taken 
to have the clothing neither too tight nor too loose. In the former case, the free 
movements of the chest, abdomen and legs are interfered with, while in the 
latter instance the clothing creases or works up and down in a manner to cause 
much discomfort. Long, warm stockings, with knitted bootees will keep the lower 
extremities protected in cold weather, and in the warm season, short, thin socks 
may be substituted. In early infancy the clothing is made long enough to well 
cover the feet, but it is not necessary to have drosses and petticoats unduly long 
so as to drag on the feet. The Gertrude patterns are excellently adapted to the 
dressing of infants as the several pieces may be put on at one time, obviating 
unnecessary handling. Diapers may be made of linen, cotton, stockinet, or canton 
flannel, according to the season, care being taken to have them snugly applied 
and warm. Watchfulness of the nurse is required to have them quickly changed 
after being soiled. 

23 



34 



DISEASES OF CHILDREN. 



The Nursery. 

This should be a large well-ventilated room with a sunny exposure. The 
temperature should be kept constant — from 68° to 70° F. during the day and 
night from 05° to 55° F., according to the age and vitality of the infant. An 
intake of fresh air without a draft may be accomplished by fitting a board under 
the lower window sash. If possible heat the room with an open fire on account 
of the ventilation. When furnace heat is employed, a thorough airing twice a 
day by widely opened windows is desirable. 

Bathing. 

After the cord has separated, a daily bath may be given. For the first six 
months the temperature of the water may vary from 98° to 100 c F. ; from six 
to twelve months. 95° to 98° F., and after one year it may be as low as 90° F. 
A good grade of soap — French or castile — may be used, and the lather removed 



M i. 



Fig 




*Sjr 




The cariole is suitable for out-door sleeping and a safe play-place in 
daytime. 



by plunging the infant in the water. The skin must be thoroughly but gently 
dried without undue friction, and the folds of the skin and genitals powdered. 
The prepuce is to be retracted to prevent the collection of smegma. Finally, 
tbe eyes and mouth may be cleansed with a warm solution of boric acid. When 
the skin is thin and irritable, or the seat of eczema, bran baths may do well. 
In severe cases of eczema, the skin may be cleansed by rubbing with sweet oil 
or vaselin. 

Exercise and Fresh Air. 

When awake, the infant should not be allowed to lie continuously in its 
crib, as the gentle exercise of being held or carried about is beneficial. They 
should always be taken up for feeding. The arms and legs must not be so 
constricted by the clothing as to prevent easy movements and, when undressed, 



HYGIENE OF INFANCY. 25 

a little time for free play of all the muscles is beneficial. In warm weather, the 
infant can be taken out of doors as early as the second or third week, in spring 
and fall at from four to six weeks, but if born in winter, unless the weather is 
mild, it may be wiser to give it its airings in the house until spring. In cold 
weather it is best to give the outing between 10 a. m. and 3 p. m. when the sun 
is out, but the face and eyes must be carefully protected from the sun's rays. 
Never expose an infant to wind. When the temperature of the air is below 
30° F. it is better to stay at home, except in the case of very strong infants. 
The baby can sleep out of doors, but care must always be taken to see that it is 
sufficiently warm during the winter months. In very cold weather or when there 
is melting snow, the infant may get fresh air by being warmly clothed, put in a 
room with a sunny exposure and have the window opened. The room must then 
be otherwise closed to prevent a draft. It is possible in this way to avoid the 
dust of the streets in windy weather. It is likewise safer to take the fresh air 
in this manner in damp, foggy weather when there is no sun. 

General Habits. 

It is well to start early in training the infant to habits of regularity. 
Sleep is encouraged by putting the infant in its crib with a firm mattress, 
but with the head low, resting on a folded pad, darkening the room, and 
attending to proper ventilation. Eocking as a preliminary or accompani- 
ment of sleep is undesirable. If feeding-time comes during sleep the 
infant can be awakened for this purpose, as he will usually sleep again aftei 
nursing or learn to wake at the proper time. The nurse need not hasten 
to take a baby up the moment it arouses and cries, as it will frequently go 
to sleep again after a few moments of restlessness. During wakeful hours, 
and especially late in the day, the infant must not be excited by too much 
playing and attention, as this induces delayed and disturbed sleep. The 
very young infant should sleep most of the time, from eighteen to twenty- 
two hours daily during the first months. At six months the baby usually 
sleeps two-thirds of the time, and at one year over half the time. 

Much can usually be accomplished by an early training of the bowels. 
As early as the third month the infant can be placed at regular times on a 
small commode for this purpose, taking care to support the baby in the 
proper position. At a year, efforts may be made to train the bladder by 
encouraging the young infant to indicate his desire for urination. After 
many trials progress will be made in this direction. 

The greatest regularity in feeding must be entailed from the first, but 
the necessary details will be considered in the chapter on feeding. Water 
must always be regularly given, even the newly-born getting a few teaspoon- 
fills daily. 

The young infant must always be kept fjuiet, as the rapidly growing 
nervous system suffers from romping and too much attention. This must 
especially be enforced late in the day. 



CHAPTER V. 

WEIGHT AND DEVELOPMENT. 

It is important to have a record of the birth weight in every case. 
The male infant usually weighs a little more than the female. In a series 
of 200 cases examined by the authors the males weighed from 6 to 8 pounds 
and the females from 5J to 7 pounds. As many of these were born in 
institutions the averages of light weight were fairly large. Seven pounds 
may be considered a good average birth weight. As far as initial weight 
may be considered a gauge of vitality, 6J pounds will show a good vitality, 




Fig. 9. — Normal infant at 3% months. Typical attitude on ventrum. 

5-J pounds a rather poor, and from 4 to 5 pounds a very poor vitality 
at the start. During the first few days there is generally a loss of from 
four to six ounces, after which there should be a steady gain. It must be 
remembered, however, that babies are apt to gain irregularly at short 
intervals. One day the infant may show a gain of an ounce and the next 
day a quarter of that amount while doing perfectly well. Again, the weight 
may remain stationary for a day or so, and then jump up two ounces in 
twenty-four hours. According to Eotch, there should be an average daily 
gain from birth to five months of 20 to 30 gm. (two-thirds of an onunce to 
an ounce), and from five to twelve months of 10 to 20 gm. (one-third to 
two-thirds of an ounce). This would mean an average weekly gain during 
the first five months of about four and a half ounces to seven ounces, and 
from five to twelve months of from about two and a half to four and a half 
ounces. 2fi 



WEIGHT AND DEVELOPMENT. 



27 



The infant 
treble it at tw 
by the same per 
constructed for 
During the first 
months, once in 
Careful records 

The length 
in the female. 



should double its birth weight at five or six months, and 
elve to fifteen months. The weighing should be done 
son either on grocer's scales or those lever scales specially 
infants. Daily weighings are deceptive and undesirable, 
six months, once a week is sufficient, and, in the second six 
two weeks is often enough in cases that are doing- well, 
should be kept, and charting is convenient for reference, 
of the new-born baby is slightly greater in the male than 
In the series already noted, the males averaged 50 cm. 




Fig. 10. — Normal infant. Typical attitude on dorsum. 



(10.(3 inches) and the females 48.6 cm. (19.1 inches). In private practice, 
with healthy parents, the length will average about 20 inches. Growth in 
length is most rapid during the first month, a little less so during the 
second, the rapidity decreasing with each month. The following figures are 
taken from Botch : The average increase for the first month is about 4.5 
cm. (If inches) ; for the second month about 3.0 cm. (1-J inches) ; for the 
third to the fifteenth month about 1 to 1.5 cm. (? to f inch) ; for the first 
year about 20 cm. (8 inches) ; for the second year about 9 cm. (3| inches) ; 
for the third year about 7.4 cm. (3 inches). 

Just after birth the trunk, arms, legs, and head have peculiar confor- 
mations. The body is of an elliptical shape, with the Widest part at about 
the center over the liver, in the region of the lower ribs. The two ends of 
the ellipse, represented by the thorax and pelvis, are small and not well 
developed. The arms are stronger and better developed than the legs. 
During intrauterine life the baby is placed in a sort of squatting position 
with the legs drawn up and curled inward. This explains why the legs of 



28 



DISEASES OF CHILDREN. 



the young infant are not straight, but show a decided bowing of the tibia 
and fibula. The soles of the feet also tend to point inward. The head is 
larger than the chest at this time, with a very short neck, and the baby 
assumes a position of general flexion. 

While infants at birth may vary in size, each individual should develop 
in proper proportion, the various parts of the body bearing a symmetrical 
relationship to one another. The circumference of the head is greater than 




LENGTH 




20.7 



LENGTH 



WEIGHT 
7LBS.12 0Z. 



NEWBORN 




26.2 



LENGTH 



WEIGHT 
15.4 LBS. 



6 MOS. 



27.7 



WEIGHT 
18 LBS. 9QZ. 



Fig. 11. — Diagrammatic table of relative measurements. 

the circumference of the chest at birth, and remains so up to the middle of 
the first year, when they begin to approximate in size; at the end of the 
first year the chest expands to a greater circumference than the head. If 
later than this time the circumference of the head remains greater than that 
of the chest, it is an indication of rickets or hydrocephalus. The schematic 
diagrams done in scale from 200 measurements will show to the eye the 
average relationships found at various ages. 



WEIGHT AXD DEVELOPMENT. 



29 



The Head. — The sutures of the skull should be ossified by the sixth 
month; the posterior fontanel closes at the end of the second month and 
the anterior fontanel from the sixteenth to the eighteenth months. Any 
deformities of the head due to prolonged pressure in difficult labors are 
usually overcome durina" the first few weeks. After birth and with increase 




LENGTH 



29.8 



WEIGHT 
22 L3S. 2 OZ. 



18MOS. 




LENGTH 



32.0 



WEIGHT 
24 LBS. 



FTG. 



24 MOS. 

12. — Diagrammatic table of relative measurements. 



in age, there is noted a gradual and steady enlargement of the great circum- 
ference of the skull, and, from this, of its estimated volume. Although no 
intellectual growth can be said to take place under two years, there should 
be an active evolution of the front of the brain, with increase of the percep- 
tions. The first rapid growth of the brain after birth is more in bulk than 



30 DISEASES OF CHILDREN. 

in the size and complexity of the convolutions. Hence in early infancy the 
higher centers have but a slight development and function. With proper 
evolution, the convolutions grow and become arranged in functional groups, 
which groups, by their growth, alter and modify the shape of the infantile 
skull. If the skull is small or improperly shaped in any part, the brain in 
such area is imperfectly developing. A certain amount of asymmetry is, 
however, found in all skulls as in other members of the body and, unless 
very marked, has no great significance. 

The principle of biology that the development of the individual repro- 
duces on a small scale the development of the race, is well shown in the 
infant's brain. The higher centers and the association fibers are developed 
late in the child; they are likewise the latest acquirements of the race. 
The lower and more fundamental animal traits are transmitted by inherit- 
ance in greater degree than the higher ones. 

The skull changes considerably in its proportions during the first 
years of life, and then more slowly up to the end of the seventh year, when 
it has very nearly attained its full size. At birth, the circumference of 
the head averages from thirteen to fourteen inches, at the end of the 
second year about eighteen inches, at the seventh year about twenty and 
a half inches, and at the completion of growth twenty-two or more inches. 

Just after birth the brain and nerve centers act only automatically, or 
by reflex action. Touch and taste are present at birth, but the baby is 
deaf for the first few days and it will not follow an object with its eyes 
until the third week. The eyes should never be exposed to bright lights. 
By the third month the baby reaches out its arms for objects and may 
recognize individuals. The rudiments of memory are now developed, and 
by the fourth or fifth month a few people may be remembered and recog- 
nized. It is not until the third year, however, that memory develops very 
rapidly. Efforts at speaking usually begin at the end of the first year 
when single words may be uttered. And at the close of the second year 
short sentences may be tried. 

The Spixe. — The spinal column is curved but very flexible. In early 
infancy the so-called normal curves are not developed above the sacrum, 
but there is one long curve in the shape of a convexity above the latter 
bone. "With the strengthening of the spinal muscles, and when the child 
begins to stanrl and walk, the normal cervical, dorsal, and lumbar curves 
begin to develop. As the child grows older the spine becomes less flexible 
and more rigid with increased power in the spinal muscles. There is, 
however, much more flexibility all through childhood than in adult life : 
when the spine loses its mobility, and especially when it is stiff or painful 



WEIGHT AXD DEVELOPMENT. 31 

on motion, caries may be suspected. At birth the spinal cord extends as 
far as the third lumbar vertebra, while in the adult the lowest portion of the 
cord is opposite the second lumbar vertebra. The spinous process of the 
fourth lumbar vertebra is about on a level with a line drawn between the 
highest points of the crests of the ilia. 

Glaxds axd Yisceea. — The lacrimal glands are usually not developed 
sufficiently to shed tears for three or four months. The diastase-forming 
organs — the salivary glands and pancreas — act very feebly during the 
first two or three months. The sebaceous glands are early active, as seen 
just after birth in the vernix caseosa and later in dry seborrhea. 

The thymus is large at birth, increasing slightly in size to the end 
of the second year and then remaining uniform in size until puberty, when 
it undergoes atrophy. 

The stomach is somewhat like a vertical sac at birth, but gradually 
develops in a horizontal direction; the intestines are relatively long with 
a sigmoid flexure that is accentuated and with sharper curves than in older 
subjects. The intestinal muscles are weak, which explains the ease with 
which the bowel becomes distended with gas. The appendix is very long 
and narrow in lumen. The liver is large, reaching a little below the free 
margin of the ribs. 

The bladder is well developed and usually extends up into the abdominal 
cavity on account of the smallness of the pelvis. In female infants the 
bladder may be mistaken for the uterus at autopsy. The testicles should 
be located in the scrotum at birth, but they may remain undescended in 
the abdomen or caught in the inguinal canal. 

The Muscles. — In the musculature, the greatest relative strength 
is shown in the hands and arms for a time after birth. At about three 
months the muscles of the neck have developed sufficiently to allow the infant 
to hold up its head in an uncertain way. At the seventh or eighth month 
the muscles of the back have become strengthened so that the baby can 
sit up, and shortly after this it may be allowed to creep. Free play should 
be given to the muscles of the arms and legs from the first, as muscular 
and bony development are thereby encouraged. The bones of the legs thus 
grow and straighten out. but this will be checked if the infant is made to 
sustain the weight of the body too soon. The average baby should not be 
encouraged to stand before the twelfth month. Efforts to walk may be 
started from then on to the fifteenth or sixteenth months. When walking 
has been established, the legs should be straight. 

Dextitiox". — .The process of dentition begins early in intrauterine 
life, and the cutting of the temporary or milk-teeth should be completed 



32 DISEASES OF CH1LDKEN. 

at the end of infancy. At birth, although nothing but smooth gums are 
to be seen, the alveolar processes enclose the twenty temporary teeth in 
embryo. AVhen beginning to come through the gums, they usually appear 
in groups. Even in healthy infants there is often some variation in the 
order and time of the eruption of these first teeth, but the earliest to be 
cut are usually one or both of the middle lower incisors at the sixth or 
seventh month. The rest are gradually evolved, generally in the following 
order: upper central incisors, upper lateral incisors, lower lateral incisors, 
four anterior molars, four canines, and finally the four posterior molars. 
The following table may serve as a general guide : 

Middle lower incisors, sixth to eighth month. 

Upper central incisors, eighth to twelfth month. 

Upper lateral incisors, tenth to twelfth month. 

Lower lateral incisors, twelfth to fifteenth month. 

Four anterior molars, fourteenth to sixteenth month. 

Four canines, eighteenth to twentieth month. 

Four posterior molars, twentieth to thirtieth month. 

As in other functions there is more or iess variation within the limits 
of health ; such irregularity as the lateral incisors being cut before the 
central incisors may occasionally be seen. In rare cases infants are born 
with teeth, but these are poorly developed and lost early. Certain unusual 
cases of rickets, contrary to the common rule, may show very early denti- 
tion, perhaps beginning as early as the third month, but such teeth are 
poor. 

Delayed Dentition. — Much delay in teething is an evidence of 
faulty nutrition or constitutional disease, principally rickets. If an infant 
has cut no teeth by the end of the first year there will nearly always be 
marked evidences of rickets present. The latter disease is the commonest 
cause of delayed dentition. The teeth of rickety children are often poorly 
developed and prone to decay, even the second dentition may be similarly 
affected by this disease. Cretinism is another cause of very slow dentition. 
In general, bottle-fed babies are slower in cutting teeth than those brought 
up on the breast. 

Disturbances of Dentition. — Many bodily disturbances formerly 
attributed to teething are now known to have other causes that have been 
revealed by more accurate diagnosis and pathology. This is a period of 
rapid growth and instabilitv, especially of the digestive and nervous sys- 
tems. Many troubles at this time are due more to faulty care and feeding 
than to any normal physiological activity and growth. Still a certain 
number of infants do show disturbances at this time that are apparently 



WEIGHT AXD DEVELOPMENT. 33 

due to the eruption of teeth, as careful examination fails to show other 
cause. There may be evidences of nervous discomfort shown by constant 
restlessness and fretfulness, disinclintaion to take food, and various grades 
of indigestion. There is drooling with swollen gums, and the infant 
keeps putting its hands into its mouth. A light, irregular temperature 
may also develop that will be aggravated by indigestion if food is forced 
in too great amount or strength. In a few cases the infant seems much 
sicker, with high fever and severe nervous symptoms, such as semi-stupor 
or convulsions. Rickety babies are prone to the latter. Most cases, how- 
ever, show the disturbances of dentition rather by an aggravation of any 
existing trouble that otherwise might hardly be noticeable. 

The treatment consists in careful regulation of the diet, wdiich will 
usually take the form of temporarily weakening the food, and in giving a 
sedative, such as sodium bromid. Incising the gums is not advised. Any 
diarrhea at this time must receive prompt and careful attention. 

Cake of Temporary Teeth. — The teeth must be cleansed twice 
daily by gently rubbing up and down with a very soft, wet tooth-brush. 
The health and preservation of the temporary teeth are necessary to favor 
a good set of permanent teeth. Any pyogenic germs allowed to lodge in 
the roots may injure the permanent teeth; milk-teeth must accordingly 
be filled if carious and preserved as long as possible. They also tend to 
preserve the alveolar shape. 

Permaxext Teeth. — There are thirty-two in the complete set. 
The first molars are usually the earliest teeth to appear in the second 
dentition, at the sixth or seventh year. Then the central and lateral 
incisors, from the seventh to the ninth year; the bicuspids from the ninth 
to the tenth year ; the canines from the twelfth to the fourteenth year ; the 
second molars from the twelfth to the sixteenth year; and the third molars, 
or wisdom teeth, from the seventeenth to the twenty-first year, or even 
later. 

The proper development of the permanent teeth may be interfered 
with by malnutrition or repeated attacks of stomatitis which may cause 
a poor formation of dentine and enamel. The ends of the incisors and 
molars may show constrictions and erosions. Carious teeth frequently 
cause earache, neuralgia, adenitis in the the neck, and poor nutrition from 
chronic indigestion due to imperfect mastication. 

Hutchix"SOX~\s Teeth. — Congenital syphilis will sometimes induce 
a change in the upper central incisors of the permanent teeth only, known 
by the name of their discoverer. They are small and peg-shapen\ with 
scooped-out grinding edges, usually deflected inward ; occasionally they 
are deflected outward. 



34: 



DISEASES OF CHILDREN. 



Growth during Childhood. 

The increase in weight and height depends upon race and climate 
as well as on the size and physique of the parents. It is thus evident that 
no absolute rules can be given for comparison that will apply to all 
children. We have already given data as regards infancy, when growth 
is steady and rapid. After the period of infancy, growth is not relatively 
so rapid and takes place more in cycles. It depends very largely upon 
good heredity, and a healthy well-nourished state during the first years 
of life. Biological researches have shown that favorable embryonic condi- 

15 K yrs. 



12K yrs. 



9>£ yrs. 



6K yrs. 



43.9 
inches 



50.0 
inches 



45.2 lbs. 



55.4 
inches 



59.6 lbs. 



62.9 
inches 



76.9 lbs. 



107.4 lbs. 



Fig. 13. — Diagrammatic table of relative measurements. 

tions and good nutrition during the earliest years have the greatest influence 
in determining the full height and development of the individual. If a 
child is fortunate in its birth and well nourished up to its fifth or sixth 
year, there will probably be a normal growth thereafter, as, even if there 
are poor conditions later on, nature will probably be able to compensate 
for them. Each individual has a certain normal size to attain which will 
usually be reached if the first years have been favorable. It is difficult to 
make up, however, for early unfavorable conditions. 

The two principal periods of acceleration of growth occur during the 
second dentition and at the period of adolescence. This roughly corre- 



WEIGHT AND DEVELOPMENT. 35 

sponds, first, with the period from six to nine years in boys and girls, and 
second, from eleven to thirteen in girls and from fourteen to sixteen in 
boys. This cycle of increase in height should precede and be shortly fol- 
lowed by an increase in weight. There also tends to be some variation in 
growth at different seasons. In a series of cases quoted by Tanner, the 
period of most rapid increase in height among seventy boys, from seven 
to fifteen years of age, was found to be from April to August, and the 
least from August to December, while the greatest increase in weight 
occurred from August to December, and the least from April to August. 

Whenever there is a rapid increase in height, the child is apt to grow 
thin and anemic, as the making of bone particularly uses up the red 
blood-corpuscles. The children then become nervous and irritable, requiring 
extra care at home and school. 

In order to present a guide of average growth, the following tables 
have been combined and compiled from the studies of Boas on the rate 
of growth in height and of Burke on the weight of American children : 

Table of height and weight of American boys. 



Years 


Average height (Boas) 


Average weight (Burke) 


Gi 


43.9 inches 


45.2 pounds 


H 


46.0 inches 


49.5 pounds 


8* 


48.8 inches 


54.5 pounds 


n 


50.0 inches 


59.6 pounds 


m 


55.4 inches 


76.9 pounds 


15£ 


62.9 inches 


107.4 pounds 


of height 


and weight of American 


girls. 


Years 


Average height (Boas) 


Average weight (Burke) 


6-| 


43.3 inches 


43.4 pounds 


n 


45.7 inches 


47.7 pounds 


8i 


47.7 inches 


52.5 pounds 


H 


49.7 inches 


57.4 pounds 


12£ 


56.1 inches 


78.7 pounds 


m 


61.6 inches 


106.7 pounds 



Mental and Moral Growth.— The mental development of the child 
must be carefully watched from the beginning. Just as the human 
embryonal life represents various upward stages of animal development, so 
the child's mind reproduces in miniature the earlier stages of the growth 
of the race. It is early necessary to recognize the various tendencies that 
manifest themselves in a growing child, so that they may be guided aright. 
It must be remembered that the child exhibits the elemental human forces 



36 DISEASES OE CHILDREN. 

and instincts. Just as the emotions are developed in the race before 
the reason, so it is with children, who can be moved by their sympathies 
long before they can be influenced by their intellect. Love is a surer guide 
for them than reason. This is the secret of success of many mothers and 
of some teachers. The most lasting impressions of childhood come through 
the feelings. 

At the end of infancy, and during early childhood, the imitative 
faculties are especially dominant. The acts of older children, of adults, 
and even of animals are faithfully copied without much idea of their 
significance. Up to the age of seven years much of the training and 
education of the child must come from imitation. Before this age nearly 
all the playing of children is imitative, shown by the delight in toys 
representing articles in real life, but after this, especially in boys, the 
games take on a more competitive form involving muscular exercise. 

There exists in some children a touch of barbarism that is merely an 
evidence of underdevelopment. Apparent cruelty, shown in a callousness 
to suffering, is sometimes seen, but this is rather due to a lack of experience 
as to the meaning of pain than to defective moral sensibilities. The con- 
duct of the child is largely influenced by the tone and temper of those 
around him, in the intellectual as well as in the moral sphere. A cultivated 
home will do more for the proper development of the child than the formal 
education of the finest schools. 

Adolescence. — The beginning of this period is a most interesting 
and critical time for the child. Up to this time, as already noted, the 
child has lived the race life, but he now begins to develop individual char- 
acteristics, and family traits come out more strongly. There is a rapid 
growth of all parts of the body, especially marked in the reproductive 
organs and the heart and lungs, with increase in blood-pressure and in 
general glandular activity. The appearance of hair on the pubes is con- 
sidered characteristic of the period. The peculiarities of sex now begin to 
manifest themselves; boys and girls cease to mingle in such an indiscrim- 
inate way as in earlier childhood. Up to twelve years there need not be 
much differentiation of the sexes, but after this they must be separately 
considered. Vague aspirations and a general restlessness show the stirring 
of new life in the child's mind. Both the emotional nature and the 
imagination become very active. Tf any trait is entirely absent at this 
time it is not apt to be seen later in life. 

As growth and development are so rapid during adolescence, nothing 
must be allowed to conflict with the physical nature at this time. Over- 
strain in school must be guarded against. , It has been proven from 



WEIGHT AND DEVELOPMENT. 37 

examinations of many school children that, as a rule, the heaviest and 
tallest, or those with the best physique, stand highest in their classes. Hence 
if a child is poorly nourished or undeveloped, the best tiling, even for his 
intellectual growth, is to focus attention on his body for a time and let his 
mind be temporarily neglected. Apparent stupidity or bad mentality in 
school children is often the result of physical causes that may and should 
be removed. Deafness, defective eyesight, enlarged tonsils and adenoids, 
and poor nutrition from lack of proper food may be especially mentioned 
in this connection. 



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SECTION III. 
THE EXAMINATION OF THE SICK CHILD. 



CHAPTEK VI. 
THE EXAMINATION OF THE SICK CHILD. 

If the physician unaccustomed, to the care of children will first learn 
what to expect to find in the normal child, he will better appreciate the 
variations in disease. He must first of all learn that a proper examination 
will take time, and that a hurried examination often leads to grievous 
errors. Having once made up his mind to be systematic, thorough, and 
painstaking, the bugbear of pediatric practice will begin to disappear, and 
diagnoses will be made where formerly there was disappointment and con- 
fusion. The younger the infant or child, the greater are the peculiarities 
from the adult type in its relation to disease. 

History. — If possible obtain the anamnesis outside of the nursery. 
It should preferably be obtained from the mother or attendant who has 
been in closest attendance upon the child. First — elicit a natural story 
as to the change from the healthy child to the sick one. If digressions are 
made they can be guided back to the proper channels. This will give a 
clue to the nature of the illness, and the further questions will be modified 
considerably thereby. For example, if the disease be one of malnutrition, 
most careful details of previous feeding from the time of birth will be 
pertinent, and the dietary life traced to the present time. Heredity and 
environment are inquired into, and previous illnesses recorded on properly 
prepared history blanks. The accompanying history card, as suggested by 
Dr. R. S. Haynes, is one that is convenient to carry, and tends to making 
recording systematic and of value without much waste of time and energy 
in writing. 

Inspection. — Thr child asleep. Trained observation is the most 
valued asset of the pediatrist. If possible, examine the child while it is 
asleep. Sit by its crib and watch it. Its general posture, if quiet or 
restless is to ho noted. The breathing as to its character must likewise be 
observed, and the number of respirations per minute counted. 

TiESPIKATTOXR. 

Xewborn, 35 to 45 First to second year. 20 to 2-~ 

First to the seconrl month. 24 to 36 Second to sixth year. 20 to 23 

Second to the sixth month, 20 to 32 Sixth to twelfth year, 18 to 20 

30 



40 



DISEASES OF CHILDREN. 



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THE EXAMINATION OF THE SICK CHILD. 41 

The respirations may be counted by the hand on the abdomen or by 
observation alone. 

If the neck and chest can be exposed without waking the child, addi- 
tional information is gained by observing the effect of the respirations on 
the supraclavicular and suprasternal spaces. 

Mouth breathing is easily detected in sleep, and the half-closed eyelids 
are indications of the weakened state. The pulse may be obtained with- 
out awakening the child with a little care, and is a mori reliable guide 
than when influenced by fright. 

If there is a gastrointestinal disturbance inspect the last soiled napkin. 

The Child Awake. — Enter the room without apparently taking much 
notice of the patient; a cheery word of greeting and an interest in his 
favorite toy will often be sufficient to disarm suspicion and win a friend. 
Xow have the patient entirely undressed. 

In the case of an infant it is best examined on a table in a good white 
light ; if a child allow it to sit up. (If you wish a child to cry at once make 
it lie down.) If the infant is crying, much valuable information is obtained 
if this is properly interpreted. (See section on signs of illness, p. 60.) 

First begin your inspection as to general development, musculature, 
emaciation, and the condition of the skin, as these factors will influence 
or modify local changes seen elsewdiere. Beginning at the head, note any 
abnormalities in detail, i. e., as to its size, shape, hair, eyes, eyelids, pupils, 
nose, mouth, gums, teeth, etc. 

The significance of abnormal conditions as seen here are given in the 
suggestive diagnostic key, which see (p. 85). Xote the contour of the 
neck, the presence of enlarged lymph-glands, the spaces above the clavicles, 
the chest itself, if well formed, or if showing any bony changes ; whether 
there is a visible apex beat or a thrill over the precordium ; the movements 
of the upper extremity, if natural, or if there is any paralysis; the finger- 
tips may give valuable information as to circulatory or pulmonary in- 
volvement ; the abdomen if distended or sunken ; the external genitals for 
abnormal formation or discharge. The lower extremities are compared to 
the upper for development, bony changes and mobility. The infant may 
now be turned over and the back of the head, spine, and rectum examined. 

The temperature should always be taken in the rectum. The best 
plan with an infant is to have it lying face down across the lap of the 
nurse. An older child is least annoyed by the procedure if the thermometer 
is inserted while the patient is lying on the side. It should be pushed past 
the sphincter and remain in the rectum for three minutes. The range in 
the normal infant varies from 98.8° to 100.2° F. Premature infants 



42 DISEASES OE CH1LDKEN. 

quite constantly have a slightly subnormal temperature. Daily variation 
of several tenths of a degree are noted. The average temperature in early 
infancy is 99° F. 

Palpation. — This is more readily and satisfactorily accomplished if 
both hands are used. 

Beginning at the head, the right hand palpates the right side of the 
body and the left hand simultaneously palpates the left side. The contour 
of the head and the fontanels are thus easily ascertained. Craniotabes, if 
present, will not escape attention. Any glands in the occipital region are 
palpated and noted if enlarged. The lower eyelids are pulled down by the 
fingers and the mucous membrane examined. Slight pressure on the chin 
will afford an inspection of the lips, teeth, and tongue; the examination of 




Fig. 15. — Method of palpating liver and spleen. 

the throat being left for the final procedure (p. 328). The hands are now 
passed over the neck to find any abnormalities in the anterior group of 
glands. Xext the shoulder- joints and the axillae are explored; at the same 
time the musculature will be estimated to aid in establishing the degree 
of physical development. The epitrochlear glands should not be forgotten 
in the examination. The hands of the patient are palpated for temperature, 
irregularities, or clubbing. The pulse is best counted when the child is 
asleep. The carotid or temporal pulse may be used if the wrist is not 
exposed. 



THE EXAMINATION OF THE SICK CHILD. 



43 



In extremely weak infants the count is taken of the heart beats at 
the apex by using a stethoscope. 
The pulse varies from : 

120 to 1-iO-in the new-born. 
110 in the first year. 
100 in the second year. 
90 in the fifth to the eighth year. 



and averages 



If the child is irritated, crying, or in pain, the pulse rate will be 
accelerated, and a note should be made of this circumstance. The force 
and character of the pulse are of as much importance as its frequency. 




Fig. 1(5. — Method of eliciting Kernig's sign. 

Tin- apex beat on the chest wall may be located, or a thrill felt in 
certain valvular diseases, and occasionally tactile fremitus will be an aid 
in diagnosis. Bony rachitic changes as the rickety rosary or Harrison's 
groove arc identified by the examination with the hands. 

The right hand on the abdomen feels for the lower border of the liver, 
while the left may palpate the spleen. If this is palpable in a child, it 
is said to be enlarged. The liver in infants when in the prone position is 
normally about one inch below the free border of the ribs. In the erecl 
position in the infant it may touch the crest of the ilium. Tumors in the 
abdomen and an enlarged kidney as in pyelonephrosis can be palpated. 



44 



DISEASES OF CHILDREN. 



The hip- joints and the knee-joints are examined for mobility. Pain, 
if elicited over the tibia, may assist in establishing the diagnosis of scurvy. 
The ankle and feet are examined for signs of edema and flat-foot. The 
lower extremities are approximated, and any abnormalities in outline suck 
as knock-knee or bow-legs will then be readily appreciated. 

The child is now induced to walk, and if postural defects warrant it 
a detailed examination of the spine for scoliosis or Pott's disease is made. 




Fig. 17. — Correct position of holding an infant for auscultation. 

The patellar reflex may be tested by raising the thigh from the table 
and allowing the leg to hang limply. A smart tap over the tendon below 
the patella should elicit a ready response. In older children it may be 
necessary to distract their attention by asking them to look at the ceiling 
or pull their interlocked fingers apart while the test is being made. 

Kernig sign is said to be present when we cannot easily extend the 
leg after it has been flexed on the thigh. The test is best made with the 
child in the prone position, using one or both lower extremities. The 
thigh is flexed on the abdomen and the leg on the thigh. When we now 
attempt to lift this leg upward and forward, a distinct sense of resistance 
is felt. Except in children with spasticity due to cerebral conditions, this 
sign is a valuable one, indicative of meningeal irritation or cerebral 
involvment. 



THE EXAMINATION OF THE SICK CHILD. 45 

The Babinski reflex or the hyperextension of the great toe and a 
flexion of the remaining toes, is elicited when the plantar surface of the 
foot is irritated by drawing the finger-nail across it. This sign is of value 
only after the second year of life, since it may ordinarily be elicited in 
perfectly normal infants. 

The Brudzinski sign, when obtained, is another evidence of marked 
meningeal irritation. It is elicited by forcibly depressing the chin to the 
chest, the chest being held to the table by the examiner's hand. When the 
sign is positive, the previously relaxed extremities are quite suddenly 
drawn up so that the child assumes a crouching attitude. 

The contra-lateral sign is quite generally obtained in meningeal cases 
and is evidenced by simultaneous flexion of the opposite extremity, when 
flexion of one extremity is made by the examiner. 

Auscultation. — This should preferably follow palpation or sometimes, 
if expedient, the inspection. Infants should be held in the arms of the 
mother or nurse, against her left shoulder with the infant's back to the 
examiner, as illustrated in Fig. 17. 

A stethoscope with a small bell is quite necessary, as the ear cannot 
advantageously be placed, for example, in the axilla of an infant. 
Children are best examined seated upon a table. The stethoscope is 




Fig. 18. — Pisek's reversible stethoscope. 

alternately passed from side to side in a line parallel to the spine, then 
the infrascapular region is auscultated, then in the axillary line on either 
side, beginning well up in the axilla, with the arms raised above the head. 

The front of the chest is gone over in a similar manner. The examiner 
should recollect that the lungs in an infant on the left side posteriorly 
reach to the eleventh rib; on the right side posteriorly, to the lower border 
of the ninth rib. In front, on the right side to the. fourth or fifth rib 
and on the left side to the ninth or tenth rib. 

Auscultation of the heart sounds is made at the apex, at the base, and 
at the second right intercostal space; if any murmurs are present they are 
traced along the lines of intensity. 

The examiner must accustom himself to pick out the normal breath 
sounds while the child is crying. After he becomes expert he will almost 



-16 DISEASES OF CHILDREN. 

prefer that the child cries while he is auscultating. So-called puerile 
breathing, that is, exaggerated normal vesicular breathing, is to be expected. 

It must further be recollected that the chest wall is thin, and the 
sounds within are therefore more readily transmitted to the ear. 

Percussion. — This should be accomplished with a sudden light tap 
because of the thin wall and the elasticity of the ribs. Percuss alternately 
from side to side, preferably first over the dorsum of the chest, then the 
anterior surface of the lungs, and finally the area of the heart may be 
mapped out. 

To do this begin your percussion near the clavicle and percuss down- 
ward until the note changes at the base of the heart. Make your line here 
with a flesh pencil. The right border of the heart is found by beginning 
the percussion well to the right of the sternum and mapping out this 
border to the apex. The left side is similarly found, by beginning the 
percussion from the axillary side. The apex beat may be located both by 
palpation and auscultation. 

The area of absolute heart dullness is relatively small in infants, but 
the fact that the lungs do not overlap the heart as they do in the adult 
should not be forgotten in percussing for the relative dullness. Percussion 
over the abdomen may be made, to obtain the lower border of the stomach, 
or a distended colon, for free fluid in the abdomen, a distended urinary 
bladder, partial intestinal collapse, or appendicial abscess. In cerebral 
cases in which fluid is suspected in the ventricles Macewen's sign should be 
sought for; this consists of a tympanitic note heard over the parietal area 
when the ventricles are distended as in hydrocephalus or in certain cases of 
meningitis. 

Mensuration. — The weight should be recorded in infants once or 
twice a week, in older children, each time they are brought to the physician 
so that he may judge of the progress of their general development. For 
infants a weight chart, such as has been devised by Dr. W. L. Carr, is 
useful. The standing height should be occasionally taken and compared 
to the weight. (See diagrammatic table, page 28, for normal relations.) 
The circumference of the head and chest and their relations to each other 
give valuable data as to disease conditions or to defects in physical develop- 
ment. The tape used should be made of nonstretchable linen or steel. If 
on auscultation or percussion signs of fluid in the chest have been obtained, 
the tape measure may show the affected side of the chest to be greater than 
the other. Mensuration of an atropic extremity or muscle groups are made 
in cases of infantile paralysis or in the dystrophies. 



PLATE I. 




Illustrating topographical anatomy of the lungs and the lobes, also 
position of the heart and relations of the bronchi. 



THE EXAMINATION OF THE SICK CHILD. 47 

Rectal Examination. — The rectum and sacrum in infants and children 
is almost straight, and because of the shallow pelvis, the so-called " pelvic 
organs " of the adult are found to be partly or wholly abdominal in the 
infant and child. 

The index-finger in the case of the child, or the little finger in the 
infant, can be used, and with the help of the other hand, bimanual exam- 
ination is easily made. The abdominal wall is usually thin and offers 
little or no resistance to the palpating finger. As a rule, no anesthetic is 
required, as the sphincter relaxes easily and the discomfort is temporary. 
The child should lie on its back with hips elevated and the thighs flexed on 
the abdomen. The examiner standing on the right side of the patient 
explores with the well-lubricated finger of the right hand, using the left 
hand for abdominal palpation. The operation is reversed for the left side 
of the body. Any abnormalities, new-growths, or diseased conditions of 
the structures and viscera in the lower abdomen can then be palpated and 
much information gained. 

In cases of tuberculous peritonitis the abnormal omental thickening 
and the matting of the intestines can often well be made out, the diagnosis 
thus confirmed, and the prognosis made more definite. Enlarged mesenteric 
and retroperitoneal glands are palpable by a sweeping motion of the intro- 
duced finger without the necessity of changing hands. 

Intraabdominal sarcomata can be quite definitely located; calculi in 
the bladder or ureters palpated, malformations of the kidneys or enlarged 
kidneys, as in hydro-, or pyonephrosis may be distinguished. 

Therefore, in an abdominal case where the diagnosis is not absolutely 
clear and uncomplicated, the examiner should not pass judgment upon a 
sriven case without recourse to a thorough examination through the rectum. 



CHAPTER VII. 
SPECIAL EXAMINATIONS. 

Exudates. — A culture and a smear should be made for examination if the 
throat, e. g., shows a suspicious membrane or if there is a serosanguinolent dis- 
charge from the nares. A sterile cotton applicator is swabbed over the area 
and gently wiped over the culture medium and upon a clean glass slide. 

The laboratory examination of these exudates is most important in differ- 
entiating diphtheria from other infections of the nose and throat. In making 
a positive morphological diagnosis of the diphtheria bacillus (Klebs-Loeffler) 
certain very definite conditions must be complied with. The smear must be 
taken from the nasopharnyx or laryngeal region. It must be grown upon a 
special media (blood serum), and it is best that it should not be grown for 
much more than sixteen hours at incubator temperature. Under these conditions 
the bacilli (if they are the Klebs-Loeffler) must show a certain morphology. 
Their characteristics are a long slender bacillus with clubbed ends, which stain 
very irregularly and often show deeply staining polar granules. 

It is not uncommon for the first, and even for the second smear to be negative 
in a case which afterwards becomes positive. This fact is explained in two 
ways. Many sore throats start out as a mixed infection, staphylococci or strepto- 
cocci predominating in the early stages. Under these conditions it is sometimes 
difficult to determine how much weight to give to a few bacilli which look diph- 
theritic when the vast majority of the organisms present are cocci. A safe 
rule in such circumstances is to regard it as doubtful and to give an injection of 
diphtheria antitoxin. A second cause for a negative smear is in diphtheria of 
the nasopharynx or larynx which is overlooked, the smear being taken from 
some place in the throat which happens to be clear of infection or which has 
been treated with disinfectants. 

A purulent secretion from the eyes may demonstrate on smear the presence 
of the Koch-Weeks bacillus or the gonococcus of Neisser. A similar test of a 
vaginal or urethral discharge may be necessary to determine the character of 
the contagion and to determine upon the necessary precautionary measures. 

The Sputum. — The examination of the sputum in infants and very young 
children is not satisfactory, owing to the difficulty of obtaining a satisfactory 
specimen. This may in a measure be overcome' by passing a stomach tube into 
the first part of the esophagus — the tube as a rule bringing up some secretion. A 
more agreeable method is to pass a cotton swab on a long sharply bent probe into 
the larynx. In order to do this the epiglottis must be held forward as is done 
in passing a laryngeal tube. Smears made from sputum obtained in this way 
will occasionally show tubercle bacilli. In lobar pneumonia it is sometimes 
possible to demonstrate rusty sputum in this way. The pneumococcus and 
influenza bacilli can be found in such a smear. 

Gangrene of the lungs is characterized by the offensive odor and by the 
color and fluidity of the sputum. Such sputum will separate into layers, with 
a thick brownish deposit at the bottom, a clear fluid in the middle, and a 
frothy layer on the top. 

When an empyema ruptures into the lungs the sputum is composed almost 
entirely of pus. and is thin and liquid. 

In those cases where bronchiectatic cavities have formed, the sputum is 
abundant and thin, and on standing separates into a layer of pus and one of 
mucus. If the cavities are large, putrefaction can take place, and large amounts 
of thin, foul-smelling gray-green fluid may be coughed up. 

The Gastric Contents. — The examination of the gastric juices in infants and 
small children has not developed any special diagnostic features of importance. 

48 



SPECIAL EXAMINATIONS. 49 

Much can be learned in this way as regards gastric motility, but aside from this 
such examinations have an astonishingly small value. 

The Feces. — It is certain that the feces are not examined as frequently as 
they ought to be. Much can be learned regarding the well-being of the infant 
and the small child by a systematic inspection of the stools. As a rule the whole 
stool is not necessary, one or two drams being a sufficient amount. The exam- 
ination should be made as promptly after the passage as is possible, as the stool 
undergoes putrefactive and fermentative changes if allowed to stand. In exam- 
ining for ova an old stool may be used. 

The reaction of the stool of course changes rapidly on standing. In a general 
way it may be said that a strongly alkaline reaction in feces which have recently 
been passed, suggests protein putrefaction, and that an acid reaction points 
towards a disturbance in the digestion of the fats. 

An excess of muscle fiber, connective tissue or vegetable fiber can be deter- 
mined by placing a small piece of the stool under the microscope. If Lugol's 
solution is added, the starch granules are stained blue or violet. There should 
be practically no unchanged starch in the normal stool. An alcoholic solution 
of Sudan III or scharlack R stains fat globules red. and the fatty acids a some- 
what lighter color. The casein is soluble in a 5 per cent, solution of HC1 or in 
a little acetic acid, and is hardened by the addition of formalin. Coagula 
composed of casein, or of mucus plus fat, fatty acids and insoluble soaps are some- 
times found in the stools of infants. Most of these coagula are of the latter 
type, though occasionally true casein curds are present in the stools. The 
point can. as a rule, be quickly determined by shaking out a few of the masses 
in ether — those due to fatty acids, soaps, etc.. are dissolved by the fats going 
into the solution with the ether. 

Blood in the feces can be identified by adding 10 drops of freshly prepared 
alcoholic solution of resin guaiac and 30 drops of ozoned (old) turpentine to an 
ethereal extract of the stool. Another method is to dissolve a few granules of 
benzidine in 2 c.c. of glacial acetic acid. A small fragment of the stool is mixed 
with 2 c.c. of water and boiled. Ten drops of benzidine-acetic acid solution and 
3 c.c. of a 3 per cent, hydrogen peroxide solution are mixed in a test-tube and a 
few drops of the cooked emulsion of feces are added. 

In both these tests a greenish or bluish color shows the presence of blood. 
The benzidin test is extremely delicate, and may be positive if the patient is 
eating meat. 

Ova. — Any of the cestoda may exist in the intestinal tract of children. 
Their identification depends upon finding the ova in the stool — as a rule not 
a difficult matter with the more common forms, though during the earlier stages 
of the infection a long and careful search must be made. 

The Cerebrospinal Fluid. — The examination of the spinal fluid has great 
diagnostic value. The normal fluid should be collected with absolute surgical 
cleanliness so that if necessary cultures on blood serum can be made: and care 
should be taken not to get a " bloody ? ' puncture, for even the smallest quantity of 
blood obscures the macroscopic appearance of the fluid, and also makes a 
eytological examination impossible. 

In meningitis there is always an exudate of cells, which makes the fluid 
more or less cloudy. In tuberculous meningitis the cellular exudate is sometimes 
so slight that the fluid appears clear unless carefully examined. 

The normal fluid contains less than 12 cells to the e.cm. and any number over 
20 should be considered pathological. To make this determination the fluid 
should be examined before any coagulation takes place. 

A preponderance of polynuclear leukocytes in the exudate denotes a non- 
tuberculous meningitis, except in the early stages of the disease when they may 
be present in large numbers. On the other hand, when a majority of the cells 
are either large or small lymphocytes, tubercle bacilli should be looked for. 
Syphilitic fluids as a rule show a relatively large percentage of lymphocytes. 

In epidemic spinal meningitis it is always possible to find the diplococcus 
intracellularis. In the earlier stages of the disease they are more easily found 
than later: and a few days after the injection of Flexner"s serum it may be 



50 DISEASES OF CHILDREN. 

almost impossible to find thern. They are gram-negative, and intracellular. 
Occasionally an acute meningitis is caused by the pneumococcus, influenza bacillis 
and still more rarely by otber organisms, such as typhoid bacilli. The diagnosis 
of these latter conditions depends upon cultures and the agglutination tests. 

To find the tubercle bacilli in the spinal fluid often requires hours of patient 
search. If the fluid is allowed to stand for a short time there appears at the 
center a thin film of fibrin. This should be removed and dried on a cover slip. 
The fluid itself should be centrifuged for one-half to one hour at 2.500 revolutions 
per minute, and the sediment dried on the same cover slip as is the fibrin. After 
staining it is possible to demonstrate in nearly 100 per cent, of the cases the 
Bacillus tuberculosus. The diagnosis can also be made by inoculating a little 
of the sediment into a guinea-pig. 




Fig. 19. — Method of performing subdural or lumbar puncture. 

A Wasserman reaction may also be made with spinal fluid, and it is 
apparently as dependable as when blood serum is used. (See also page 58.) 

Xoguchi has devised a method which may prove applicable to some of 
the ill-defined inflammatory conditions of the meninges, such as the so-called 
serous meningitis in which micro-organisms and inflammatory cells cannot as a 
rule be demonstrated. The method is as follows : 

To one or two parts of cerebrospinal fluid are added five parts of a 10 per cent. 
butyric acid solution in a physiologic salt solution. This is boiled for a brief period. 
One part of a normal solution of NaOH is then quickly added, and the whole boiled once 
more for a few seconds. 

The increased amount of protein in the cerebrospinal fluid is indicated by the 
appearance of a granular or floeenlent precipitate. Normal cerebrospinal fluid 
gives a slight opalescence or sometimes a turbidity, but not a granular precipitate. 
unless allowed to stand for a number of hours. This test is positive in syphilitic 
and parasyphilitic conditions, and in all cases of inflammations of the meninges 



SPECIAL EXAMINATIONS. 51 

caused by micro-organisms. It suffices to distinguish normal from pathological 
cerebrospinal fluid, and especially that form of pathological fluid which is altered 
through an increase in its protein content. 

Cerebrospinal fluid often contains a sugar reducing agent, but this condition 
is only of confirmatory diagnostic value so far as is known at the present time. 

Technic for Subdural or Lumbar Puncture. — One of two positions may be 
selected : the sitting posture, or the child may be placed on its side with the 
spinal column well flexed. Cleanse the lower lumbar area until the parts are 
surgically clean. The operator, who has thoroughly cleansed his hands then takes 
the sterilized needle in his right hand, as one holds a pencil in writing, and 
inserts the same at right angles to the body through the skin and soft parts 
between the third and fourth lumbar vertebra 1 (see Plate II). This point is 
conveniently located by placing the index- and third fingers of the left hand on 
the highest points of the respective iliac crests, the middle finger being placed 
on the vertebral spine which is on the same level as the crests above determined. 
This is the third lumbar spine, and the point of election is midway between this 
spine and the one immediately below it. The needle meets with only cartilag- 
inous resistance if properly inserted, and should be introduced about three- 
quarters of an inch. If bony resistance is encountered, withdraw slightly (not 
entirely) and change somewhat the angle of insertion. If the spinal canal is 
entered a free flow of fluid follows ; then allow the fluid to escape into a sterile 
tube. At the same time collect two or three drops in a culture tube of blood 
serum. When 15 c.c. have been collected quickly withdraw the needle and seal 
the puncture wound with cotton and collodion. 

Technic for Aspiration of Pleural Cavity. 

Aspirated fluid from the chest when slightly clouded is microscopically ex- 
amined for the presence of pus-cells, and operative interference is often based 
on their numerical estimate. 

Sterilize a needle and clean the chest wall over the site of election, in all 
cases observing strict surgical asepsis. 

Place the child in a sitting posture with both arms drawn well forward 
then, holding the needle at a right angle to the body, puncture in the midscapular 
or in the posterior axillary line (preferably the former), the point of election 
being the interspace just below the angle of the scapula. Insert the needle about 
three-quarters of an inch. From the fluid a culture is made and the remainder 
is collected in an empty sterile tube for further examination. Seal the puncture 
wound with cotton and collodion. 

The Urine. 

Only the more important diagnostic features of urinary analysis will be 
touched upon. The subject has a great practical interest not only for the 
diagnosis of kidney lesions, but also for the recognition of changes in other 
organs. 

The specimen should as far as possible be a part of the whole 24-hour urine, 
in order to avoid the well-known variations in the specific gravity, the reaction 
and other properties of the urine. For microscopical examination it is important 
to have a fresh specimen as decomposition may change the entire picture within 
a few hours. Fermentation sometimes results in the entire disappearance of 
small amounts of sugar and greatly reduces the total percentage where it is 
present in larger quantities. All such changes may at least be delayed by keep- 
ing the urine in the ice-box or by the addition of small amounts of salicylic acid, 
thymol, chloroform or chloral. 

Quantity. — Infants pass a relatively larger amount of urine than do older 
children and adults. Furthermore, the quantity fluctuates widely from day to 
day. according to the amount of fluid food taken and the activity of the bowels 
and the skin. The average amount passed during the first week of life is from 
three to twelve ounces a day. and during the first two months from five to 
thirteen ounces. From this time up to the end of the second year the quantity 



52 DISEASES OF CHILDREN. 

of urine passed gradually increases, so that the average is from eight to twenty 
ounces. Between thirty and fifty ounces of urine are passed daily from the 
eighth to the fourteenth year. 

During the first two years the urine is passed as often as twice in the hour 
when the child is awake, but during sleep is retained from two to six hours. A 
fair control of the sphincters of the bladder is often obtained at two years, and 
sometimes at an even earlier period. 

The specific gravity during the first eight years of life averages 1008-1012. 
Microscopically the urine normally contains epithelial cells, mucous, granular 
matter, crystals or uric acid, amorphous and crystalline urates and the amorphous 
and crystalline inorganic salts. When prolonged and very careful examinations 
are made, hyaline and even an occasional hyalo-granular cast may be found in 
the urine of healthy infants. 

Sugar in minute quantity is not infrequently present during the first two 
months ; and traces of albumin have been observed in a fairly large number of 
cases. 

Test for Indican. 

The simplest and probably the most accurate test for indican in urine 
is performed as follows : to a clean test-tube add four to six drops of a 1 per 
cent, solution of potassium permanganate, then 1 or 2 c.c. of chloroform, then 
10 c.c. of concentrated hydrochloric acid C. P., and lastly 10 c.c. of urine. Invert 
the test-tube two or three times to thoroughly mix and allow to stand five 
minutes. The ethereal sulphates in the urine are broken down by the hydrochloric 
acid and are oxidized by the potassium permanganate to indigo which is dissolved 
by the chloroform, giving a deep blue color, the intensity of which when compared 
with the color scale (Plate III) determines the extent of the putrefactive changes 
occurring in the intestine. 

The presence or absence of indican in the urine is important, as its presence 
indicates an excessive putrefaction of the protein substances in the intestines. 
The test can also be made by placing an equal amount of urine and hydrochloric 
acid in a test-tube to which is added one drop of peroxide of hydrogen. If much 
indican is present a dark blue or purple color is produced, which may be shaken 
out with chloroform. The reaction may not appear at first but may come out 
after standing for a time. If more than one drop of hydrogen-peroxide is added 
the blue color may be bleached. In alkaline urine the indican is usually destroyed. 

Transudates and Exudates. 

Rivalta has recently perfected a test for accurately distinguishing between 
transudates and exudates. 

Add 2 drops of acid acetic (glacial) to 100 c.c. of water to make the test 
solution. Allow the exudate, a drop at a time, to make its way down through 
the dilute acid medium and it will leave a bluish trail in the water like a puff 
of cigarette smoke, each drop leaving a separate trail. The fluid remains clear 
and unaltered if the added drop be that of a transudate. 

The Roentgen Rays. 
The Roentgen rays are, of late, assuming a more important role in pediatric 
practice. Foreign bodies swallowed or aspirated, fractures and dislocations, bone 
changes and tumors, displaced viscera, consolidations and exudations in the 
thorax are conditions in which we can obtain valuable aid. In the stomach and 
intestinal tract the use of bismuth enables us to obtain exposures which show 
clearly the patency or non-patency of the pylorus, congenital conditions such as 
megaiacolon or transpositions of portions of the tract. Short exposures should 
be made with the best tubes and sensitizing sheets. An anesthetic is sometimes 
necessary for unruly children. 



PLATE III. 




5luo 



»-o< 



* k 






cccc. 

z 



SPECIAL EXAMINATIONS. 53 

Lesions in Children in Which the X-Ray May Be Used as an Aid in 

Diagnosis. 

Foreign bodies (metallic). 

Fractures or dislocations. 

Bone diseases. 

Joint diseases. 

Renal, ureteral or vesical calculus. 

Kidney — (displaced, dilated or deformed) (injected with collargol or air). 

Lungs: Incipient tuberculosis or any other lesion of the parenchyma. 

Thorax : Mediastinal glands. Pleurisy with effusion or empyema. 

Head: Infection of accessory sinuses. Lesions of the inner table of the skull. 

Teeth : Malposition or unerupted teeth. 

Oesophagus : Stricture dilatation, diverticulum. 

Stomach : Size, shape and position ; stenosis or spasm ; negative diagnosis of 
carcinoma of pylorus. 

Colon : Size, shape and position ; adhesions, kinks, new growth, motor 
insufficiency. 

Small intestine : Identification of duodenum, jejunum, ileum and motor 
insufficiency. 

Intussusception. 

Malformations of the rectum. 

Hemoglobin. 

The quantitive determination of hemoglobin must be made with fresh blood, 
whatever the method used. The Tallqvist hemoglobinometer is the cheapest 
and simplest instrument on the market, consisting merely of a color scale and 
special filter paper. The blood is absorbed by a small piece of the filter-paper, 
and after the glazed surface has disappeared by the blood soaking into the paper, 
the spot is compared with the various colors of the scale in daylight, until the 
shade is approximately matched. The error of this method is about 5 per cent. 
This error may be reduced by taking care to have the drop of blood on the 
filter-paper at least twice as large as the ring through which the comparison of 
the colors is made. 

The Dare hemoglobinometer is a simple and satisfactory instrument, but 
is expensive and easily broken. It has the advantage that it may be read by 
artificial light. In this instrument the fresh blood is compared with a colored 
glass picture wedge. With practice the error of the instrument is less than 5 
per cent. 

The Fleischl-Miescher hemoglobinometer is expensive and rather difficult 
to use. but probably is the most accurate instrument at our command and is 
generally found in well-equipped laboratories. 

For the first few days after birth the hemoglobin percentage is high, 
and then sinks so that it is lower in the first year of life than later, according 
to Perlin varying from 58 to 78 per cent, by the Fleischl-Miescher hemoglobin- 
ometer. After the nursing period, it gradually rises to 75-85 per cent, in the sixth 
year, reaching the average for adults at about the tenth year. 

Red and White Blood Counts. 
In making the red and white count, fresh blood must be used. The blood 
is drawn into a pipette and diluted 1 :10 for the white cells and 1 :100 for the red 
cells. It is best to make the count immediately, but by passing a rubber band 
around the ends of the pipette it may be carried for some time, especially if 
Hayem's* solution is used. The error in counting the red colls in one hundred 
squares is 5 per cent, or over. To reduce this error to ."> per cent.. 400 squares 
should be counted. In the white blood count 200 leukocytes must be counted to 
bring the error under 5 per cent. 

* Mercuric chloride, 0.5 gram ; sodium sulphate, 5 grams ; sodium chloride, 1 
gram. Aq. dest 200 c.c. 



54 



DISEASES OF CHILDREN. 



Red Cell Count in Early Life. 

In early life the average number of red blood-cells is somewhat higher than 
in the adult. During the nursing period it averages about 5,580,000, with a 
maximum during the first week of life. In the second year the number is about 
5,680,000, and from the second to the sixth year the average is rarely under 
5,900,000, girls showing a slightly lower count than boys. In infants and young 
children from day to day a fluctuation of a million cells may occasionally be 
found. 

White Cell Count. 

The white cell count in infants and young children is very different from that 
of the adult, as may be seen from the following table : 



Age 


Average number 
of leukocytes 


Maximum number 
of leukocytes 


Minimum number 
of leukocytes 


At birth 


15,000-19.000 

12,000 

9.000 

7,000 








16,000 
13,000 
12,000 


8,600 
6,900 
5,400 




6 13 vears 






Fig. 20. — Method of making blood smear. 



The blood of children is much more sensitive to sitmuli than is the case 
in adults, so that there is occasionally a very high leukocytosis, from a small 
cause, as for instance a leukocytosis during digestion of 20,000-25,000. Any 
increase in the leukocytes over the maximum given in the table above is to be 
looked upon as pathological and at least requires an explanation. 

A well-marked (polynuclear) leukocytosis is to be expected in scarlet fever, 
erysipelas, diphtheria, pneumonia, acute articular rheumatism, tuberculous 
meningitis, and suppurative conditions. There is only a slight leukocytosis in 
typhoid, roetheln, mumps, malaria, and uncomplicated tuberculosis, except when 
it invades the meninges or serous surfaces, or when it becomes complicated with 



SPECIAL EXAMINATIONS. 



55 



a septic condition. There is also a high (lymphatic or myelogenous) leukocytosis 
in the leukemias. A moderate (polynuclear) leukocytosis is frequently present 
after ether or chloroform inhalation, after taking quinine, the salicylates, tuber- 
culin injections, and following saline infusions. Even more important than the 
leukocyte count is the making of a differential count. 

Blood Smears. — An important point in making a good smear is to have a 
clean slide. If new slides are used it is usually sufficient to breathe on tbem and 
polish them off with a dry towel, but old slides must first be cleaned with acid. 
One end of a slide is just touched to a drop of blood, and this slide is then 
gently touched to the surface of another slide at an angle of about 30 degrees. 
The first or smearing slide is then gently drawn over the surface of the slide on 
which the smear is being made, thus dragging the blood out in a broad thin film 
which quickly dries. The size of the drop and the speed with which the smear 
is made determine the thickness of the preparation, and not the pressure, which 
should always be light. Such a smear is used for studying the morphology of the 
blood-cells, in the search for malaria Plasmodia, and in some regions for parasites 
(filaria, bilharzia, etc.). 

Nucleated Red Cells in Infants. — In infants up to the eighth month it is 
possible to find an occasional nucleated red cell, which may be either the size of 
a normal red cell or from two to four times larger. 

The Relation of Polynuclear-Neutrophiles to Lymphocytes During Child- 
hood. — The relation of the neutrophils to the lymphocytes during childhood is 
shown in the following table: 



Age 



Nursing period . . 
Sth-lOth month . 
After 10th month 

2d year 

6th-8th year . . . 
mth-14th year . 



Polynuclear- 
Neutrophiles 



28% 
25% 
36% 
41% 
46% 
55% 



Lymphocytes 



51-59% 
56-61% 
56% 
55% 
41% 
30% 



The increase in neutrophiles occurs chiefly in the second, third, and fourth 
years, but an increase is noticeable up to the fifteenth year. 

The disease in which there is or may be an increase of neutrophilic (poly- 
nuclears) leukocytes have already been discussed under leukocytosis and, there- 
fore, it is only necessary at this point to indicate those conditions in which the 
leukocytosis is due to the increase of other cellular elements. The lymphocytes 
in typhoid are relatively increased, but emphasis should be placed on the fact 
that the total number of leukocytes are decreased, so that the white count in this 
condition will vary from 3.000-4,000. The increase in lymphocytes is chiefly 
important in the leukemias — a rare condition in children and when present 
usually of the chronic lymphatic variety. The diagnosis of the condition depends 
upon repeated leukocyte counts of 30,000 (generally 100,000) or more, made up 
almost entirely of lymphocytes, or myelocytes and lymphocytes. Von Jaksch's 
anemia or infantile pseudoleukemia resembles both pernicious anemia and 
leukemia. It is characterized by a marked anemia, enlarged spleen and (occa- 
sionally) liver, enlargement of the lymph nodes, and by an increase in the 
leukocytes to 20,000 or 50.000 (rarely 100,000) per cubic millimeter. There are 
many nucleated red cells of both the normoblastic and megablastie type. The 
leukocytes are chiefly mononuclear in form, and myelocytes are present in 
moderate numbers. It is probably a severe form of secondary anemia. 

Eosinophilia. — The eosinophils average in health from 2 to 4 per cent, of 
the total white cell count. In infancy, according to Wood, the maximum is 7.5 
per cent, and the minimum 0.5 per cent. The same authority states that during 
childhood the maximum is 12.5 per cent, and the minimum 0.7 per cent. In 
bronchia] astlhna there may be an eosinophilia of 10 to 30, or even 50 per cent. 
Scleroderma has been known to give an increase to 10 per cent. Intestinal 



56 DISEASES OF CHILDREN. 

parasites sometimes cause an eosinophilia as high as 75 per cent, especially in 
the early stages of the infection, only to fall back to normal or nearly normal 
later. In scarlet fever a moderate eosinophilia is present, in contrast to measles 
in which no such phenomenon is observed. 

Malaria. — The diagnosis of malaria can be made by finding the Plasmodia in 
the blood. These Plasmodia are present in largest numbers just previous to or 
at the time of the chill, but in the quartan and tertian types a few may be found 
at any time. In the estivo-automnal form of malaria it is often necessary to 
search for a long time before the Plasmodia are found. In some cases of malig- 
nant malaria (black-water fever) the Plasmodia disappear entirely from the 
peripheral circulation. Even one-half of a gram of quinine is sufficient to 
nullify a most careful search for the Plasmodia, so that a negative result under 
these circumstances is of little value. 

The Widal Test for Typhoid. 

Preparation of Blood. — In making a Widal test either a dried specimen of 
the blood may be used or, better still, the serum. In obtaining a dried specimen 
of blood the finger is pricked with a needle, preferably a Hagedorn needle, and 
a very small drop of blood is placed on a clean side and allowed to dry. Several 
such drops should be made in order to give the pathologist a choice and also to 
avoid losing the specimen through error or breakage. Blood serum is to be 
preferred because it is more accurate for the making of dilutions. The method 
of collecting the blood is the same as that described later under the Wasserman- 
Noguchi test. 

Dilutions. — The pathologist should always state the dilution made, and if 
there is a positive result with 1 :20 a dilution of 1 :40 and 1 :60 should be tried. 
Rarely there is a positive result in dilutions of 1 :20 in normal blood. With 
dilutions of 1 :60 for one hour Wood obtained only 10 per cent, of positive results 
during the first week, but many of these cases gave good agglutinations in one 
hour in dilutions of 1 :20. In the second week the reaction was present in about 
80 per cent, of the cases, using a dilution of 1 :60 for one hour. During the 
fourth week 8 to 9 per cent, more of these cases gave positive results. Taking 
the whole course of the disease, only 1-2 per cent, of the cases failed to react 
when the blood was frequently tested. Agglutnations to this degree, e. g., 
1 :60 for one hour, may be present for only a few days and then become weaker. 
Libman states that he has never failed to obtain a positive reaction some time 
during the course of the disease, using a dilution of 1 :20. 

The Widal reaction appears so late in dilutions which are absolutely diag- 
nostic that it is of little value in the early diagnosis of an active and well-marked 
typhoid. If, however, the clinician is in a position to interpret the test, very 
suggestive results are often obtained during the first week. A Widal has a 
great value in the diagnosis of obscure and ambulent cases, and in children 
where the symptoms referable to the intestinal lesion are not prominent. 

Tuberculin Tests. 

One of three tests may be selected for use in suspected tuberculous children. 
The skin test was superseded by the eye test and inunction test, but to-day it has 
the greatest number of advocates, since it is the most reliable and at the same 
time least annoying to the patient. The test is of the greatest value in children 
under the age of five, for it then denotes with a fair degree of certainty that 
there has been or is an active tuberculous process going on. A positive reaction 
is proportionately valuable to the age of the patient. The younger the child the 
more valuable the sign. The rapidity of the appearance of the reddened zone is 
also proportionate to the severity of the process. The reactions are usually 
graded for purposes of comparison as mildly positive, positive, and strongly 
positive. 

Skin or Von Pirquet Test. (Plate IV.) 

This is made by cleansing the forearm with ether, scarifying three small 
areas on the arm, as for vaccination, and inoculating the central one with a drop 



PLATE IV. 




The ocular, percutaneous and cutaneous tests, (a) ocular reaction; (b) 
inunction or Moro reaction; (c) cutaneous or Von Pirquet reaction. 



SPECIAL EXAMINATIONS. 



57 



of Koch's old tuberculin (obtainable in the market), using the upper and lower 
areas as controls. In from twelve to forty-eight hours (occasionally even longer) 
a reaction will be observed in tuberculous individuals. At first a reddened blush 
appears which soon becomes inflamed and resembles the firSt stages of a suc- 
cessful vaccination. The controls should show no reaction. In advanced cases 
the reaction usually fails, due to the presence of numerous antibodies in the 
blood of the child; it may be negative in cases of marked anemia, in very acute 
disease, and in mixed infections complicated by acute diseases. 

The Calmette or Eye Test. (Tlate IV.) 

In selected cases in which we are positive that the eye is normal, one drop 
of a 1 per cent, solution of tuberculin for older children and a 1/2 per cent, for 
infants, is dropped on the lower lid of one eye and the eyelid held down for 
a moment before allowing the eye to close :_ the closure should not be spasmodic, 
but gentle ; it is better to gently massage the eyelids over the eyeball for a 
moment. 

A positive reaction is indicated by a feeling of annoyance in the eye which 
ensues in from six to twenty-four hours, or even after two days. The palpebral 
or ocular conjunctiva becomes injected, later the caruncle is swollen, and. in 
intense reactions, an exudate is observed. The patient complains of having a 
" cold in the eye." The symptoms soon diminish, so that in four to five days the 
eye is quite normal again. 

The indiscriminate use of this test has led to reports of corneal ulceratiou. 
The severity of the reaction is no criterion for the intensity of the infection. 
Severe reactions may follow in incipient cases. As in the skin test, active and 
latent cases will react, but those far advanced may give a negative test. It 
should be remembered that no immunity to tuberculin is produced by these tests : 
the other eye will react : a skin test or inunction test can be subsequently made 
in the same individual. This test has been quite superseded by the Yon Pirquet 
test in this country. 

The Inunction or Moro Test. (Plate IV.) 

The Moro reaction is obtained by using a 50 per cent, tuberculin and lanolin 
ointment, and vigorously rubbing a piece the size of a split pea for a few 
moments over the site selected ; this may be. for example, the axillary or the 
interscapular region. A maculopapular eruption is produced in the tuberculous 
at the anointed area in from twelve to twenty-four hours. It may persist for 
five days to over a week, and in neurotic children may appear on the opposite 
side of the body. The test is simple, easily performed and commends itself for 
use with intractable children. 

The following table, by Von Ruck, shows that the cutaneous test more nearly 
approximates in its result to the sub-cutaneous than does the conjunctival. 





Cases 


Tuberculous 
Per cent. 


Number giving reaction 




Suspects 
Per cent. 


Non-tuberculous 
Per cent. 


Subcutaneous 

Conjunctival 

Cutaneous 


70vy 
0449 
C.-04 


S9-88 
79 20 

85-59 


63-34 
57-80 

C7-4S 


Hl-30 
13-73 
31-62 



Method of Collecting the Serum for the Wassermann Test.— Only about 
2 c.c. of the patient's blood is needed. A convenient method is to puncture the 
finger with a Hagedom needle or a sharp-pointed scalpel. The blood car be 
driven toward the extremity of the finger by coiling around it tightly a small 



58 



DISEASES OF CHILDREN. 



rubber tube or baud. This may be repeated several times, allowing the hand to 
hang down previously to each winding for a few seconds. 

The blood is collected into a glass tube of rather large lumen, drawn out at 
either end into a capillary tube. During collection utilize both capillary attrac- 
tion and gravity by holding the tube downward, or, better still, gentle suction can 
be made. After the blood is collected the two ends of the tube are sealed over a 
flame (alcohol lamp). , 

Considerable blood may be collected by compressing a vein of the forearm 
and pricking it with a sharp needle. Another method is to push into a vein a 
small sterile aspirating needle, such as is used in blood culture work. Small 
bottles (2 to 4 c.c.) with a rubber or cork stopper and sealed with paraffin make 
convenient receptacles for the blood, if it is impossible to obtain the tubes already 
described. The first method described is simple, and yet it does seem to require 
practise to obtain a sufficient amount of blood for the test. On the other hand, 
almost anyone can fill a 2 to 4 c.c. bottle by pricking a vein or by making a small 
incision. 




Fig. 21. 



The blood, if properly sealed, will keep for a number of days even at ordinary 
temperatures (four to five days at least). If kept in an ice-box, for even a 
longer time. 

Syphilis and the Wassermann Reaction. — The clinical aspects of the Was- 
sermann reaction may be summed up as follows : 

1. The Wassermann-Noguchi test has not superseded the original Wasser- 
mann test. 

2. The Wassermann and Wassermann-Noguchi test must be done by men 
especially trained for the work to obtain reliable results. 

3. A positive Wassermann or Wassermann-Noguchi is positive. The only 
other diseases which give a positive reaction are leprosy and yaws, and very 
rarely one of the infectious diseases. 

4. A negative Wassermann does not necessarily mean that the patient is 
cured or has not a syphilitic infection. It is probable that a certain number of 
syphilitics give a negative reaction ; this is especially true of those cases which 
are known as latent syphilis. Active syphilis is nearly always positive. 

5. in hereditary syphilis those children born without symptoms may give 
a negative reaction until just previous to the appearance of symptoms. If born 
with symptoms the reaction is at once positive. 



SPECIAL EXAMINATIONS. 59 

6. Under treatment with mercury or iodides the reaction generally becomes 
weaker and weaker, and finally disappears. The reaction may become positive 
again if treatment is stopped for a few days or weeks. In some cases, especially 
congenital syphilis, it is extremely difficult to make the reaction disappear under 
treatment. 

7. Children born of syphilitic parents under treatment may or may not give 
a positive reaction. It is certain that a few of these children escape infection. 

8. Frequently the last child or children which manifest no symptoms, 
though born of syphilitic parents, are negative to the Wassermann reaction. 

9. While the mothers of syphilitic infants may present no signs of syphilis, 
yet examination of the blood of the mothers gives a positive reaction in half the 
number of cases examined. The negative reaction in the other half is due to 
the latency of the disease. Enough has been accomplished to throw doubt upon 
the dictum of Colles, and it can be said that the mother of a syphilitic child has 
syphilis. 

Luetin Test. 

Luetin Test. — Brown found that in 10 untreated children only were posi- 
tive, but the 24 treated all gave a positive reaction. 

Xoguchi says that in children the reaction as a rule is negative, but as soon 
as intensive treatment is started the number of positives becomes very high. He 
obtained 90 per cent, positive reactions under these conditions in children from 
2 months to 2 years old. 

He claims the test is dependent upon the formation of anti-bodies and that 
it is truly specific. A positive reaction should not be looked for early in the 
disease. That it appears comparatively late and persists for some time after the 
Wassermann has become negative. The test is often not easily read, being in 
this respect like the doubtful von Pirquet test. It is feasible to repeat the test 
after a few weeks. A diagnosis of syphilis on the basis of a positive luetin test 
alone should not be made. As a confirmatory test it is valuable. Where there is 
a definite undoubted history of syphilis with a negative Wassermann a positive 
luetin test would call for further treatment. 

Technic. — The luetin is injected beneath the superficial layer of the skin 
(never beneath the true skin), with a small syringe and fine needle. The latter 
is held close to. and parallel with, the surface of the arm, and inserted for about 
a third of an inch. The luetin should then be very slowly injected. 

Luetin is an emulsion which contains the organisms of syphilis as well as 
the products of their metabolism. 

In the unaffected a small erythematous area appears about 24 hours after the 
injection, and disappears within 48 hours, leaving practically no effect. While 
affected individuals may show a reaction of a papular, pustular, or a torpid form. 



CHAPTER VIII. 
SIGNS OF ILLNESS IN INFANCY. 

As it is by no means easy in every case to tell exactly when or how 
an infant begins to be ill, a close observation of symptoms and their proper 
interpretation becomes highly important. Slight causes often produce 
very marked and sudden effects at this time of life. This is explained by 
the active growth of infants and especially by the rapid development and 
irritability of the nervous system. Thus a really slight indisposition may 
present the appearance of severe disease, while the converse of this is some- 
times true, as serious illness may so blunt this delicate nervous susceptibility 
as to cause the true gravity of certain cases to be overlooked. Attention 
may be called to various conditions that are evidences of some disturbance, 
and to note what they usually signify. 

Irritability of Temper. — In the absence of speech, the infant shows 
discomfort or suffering principally by cries and restlessness. If watched 
closely, it may by certain signs indicate to some extent the seat of the 
trouble. In headache, the hand will be frequently raised and held beside 
the head; in earache, the hand will be carried to the ear, and often pull 
upon that organ; in difficult and painful dentition, the fingers will be 
constantly inserted in the mouth, as if to pull out the cause of the distress ; 
irritation of the stomach and bowels may be accompanied by a continual 
rubbing of the nose. During an attack of colic, the legs are drawn up 
over the abdomen, which feels hard, and there is likewise a writhing motion 
of the body. Crying is a very constant accompaniment of all kinds of 
illness. Constant, uninterrupted crying is usually caused by earache, 
hunger, or thirst. If, after giving the baby suitable nourishment or a drink 
of water, it still keeps up a continuous, almost automatic crj y there is 
probably severe pain in the ear. This may be confirmed by pressing in 
front and behind this organ, when the baby will wince. Where there is 
some disease in the head a sudden piercing cry is uttered at certain intervals, 
between which there will probably be no fretting. In pneumonia, there is 
crying only during spells of coughing and a short time after; in pleurisy, 
there is likewise crying only during coughing, but it is shriller and shows 
more suffering than in pneumonia, and is also produced by moving the 
child and pressing over the affected side. Crying just before or after a 
movement of the bowels, with a twisting of the pelvis, gives evidence of 
intestinal pain. 

60 



SIGNS OF ILLNESS IX INFANCY. 61 

Where the hand is tightly shut, with the thumbs thrust deeply into 
the palms, and the toes strongly bent, there is much nervous irritation, 
which may eventuate in a convulsion. 

Eestless Sleep. — Much may be learned by a careful inspection of an 
infant during sleep. A well child always sleeps quietly, but, when ill, 
sleep is fitful and sometimes only possible when the infant is rocked or 
patted or carried about in the arms. If there is a constant kicking off of the 
bedclothes, so that the child will not long keep covered even in cold weather, 
it is a pretty sure indication of rickets. When it is impossible for a child 
to sleep unless the head and shoulders are raised high upon a pillow, there 
is usually some disturbance in the action of the heart or lungs. If a child 
sleeps with its mouth wide open and the head thrown back, there is enlarge- 
ment of the tonsils or adenoid tissue at the vault of the pharnyx interfering 
with natural quiet breathing through the nose. A persistent boring of the 
back of the head into the pillow points to cerebral irritation. When sleeping 
with half-open eyes, there is apt to be moderate pain present, and, if there 
is a constant movement of the lips, the discomfort is located in the gastro- 
intestinal canal. 

Changes ix the Features. — When illness is present, it is quickly 
shown in the countenance of the infant, which, during health, is in a con- 
dition of easy repose. In general, it can be stated that the upper part of 
the face is involved in diseases of the head, the middle part in affections of 
the chest, and the lower part in disturbances involving the abdominal 
organs. Thus in disease of the brain, the forehead and eyebrows will be 
sharply contracted, and the eyes sensitive to light with various changes in 
the pupils. Puffiness and swelling about the eye-lids point to dropsy, which 
is usually caused by diseases of the kidneys following scarlet fever of other 
infectious process, but occasionally by severe anemia. In pneumonia and 
pleurisy the nostrils are sharply defined, and dilate and contract with the 
movements of respiration which will appear more or less labored. The 
mouth is the feature most affected in abdominal disease, shown by a drawing 
of the upper lip and other movements indicating pain. 

State of the Discharges. — A careful examination of all the oro-ans 
opening upon the surface of the body must be made to detect any abnormal 
discharges. The ears, eyes, nose, mouth, urinary and rectal regions must 
thus be carefully inspected. 

During infancy vomiting is a frequent and early symptom when the 
stomach is distended. In such a case there may be a regurgitation of some 
slightly curdled milk after each feeding. The infant shows no distress from 
this act and continues in a good condition of health; the stomach simply 



62 DISEASES OF CHILDREN. 

rejects any excess of food above that which it can readily hold. But sudden 
and profuse vomiting, without any error in diet, may constitute the begin- 
ning of severe illness, such as scarlet fever, diphtheria, or some brain 
disease. Acute illness in early life may begin with vomiting in place of the 
chill seen in older subjects. Vomiting may simply be a sign of local dis- 
turbance in the stomach, as when mucus is ejected in cases of gastric irrita- 
tion. Where tough curds are vomited with the milk very sour, there is 
evidence of fermentation of the milk and an overacid condition of the 
stomach. If this persists, the mouth will become red and sore from a direct 
continuity of the irritation. 

Much can be learned by investigating the number and character of the 
discharges from the bowel. During the first two months there are usually 
three or four stools in the twenty-four hours, and during the first two years 
two stools a day on the average. The stools are homogeneous, of a soft, 
semisolid consistency, and of yellowish color. In cases of diarrhea or in- 
flammation they may be green, or contain hard, lumpy curds, or have an 
admixture of mucus and blood, or be of very watery consistency. Abnormal 
stools will be considered more at length in the section devoted to diarrhea. 

The urine is passed many times in the twenty-four hours, and the 
diaper may have to be changed as often as every hour. Infants vary in 
this, however, as they may go six or eight hours without voiding urine. If 
twelve hours pass without it, a careful examination must be made in order 
to reveal the cause of retention. In some cases where the urine is highly 
acid, it may be expelled when a few drops collect in the bladder, and, as 
this amount quickly dries in the diaper, there is no evidence from wetting 
that urine has been passed. A dark, smoke-colored urine may indicate 
nephritis, and thus be of great significance. Scanty urine, loaded with uric 
acid and the urates, may leave a red deposit upon the napkin simulating 
blood. 



CHAPTER IX. 
GENERAL THERAPEUTICS. 

Under this heading will be described methods and means of treatment 
that are ordinarily employed in pediatric practice. 

As these various measures are used in a number of conditions, it is 
advisable to discuss them at some length and later refer to this chapter 
when outlining the treatment for a certain disease. 

Drug Administration. 

Never prescribe a drug without a good and .sufficient reason. Prescribe 
so that the dose will be small in amount and as agreeable as possible. 
Heavy syrupy mixtures may be agreeable, but are apt to give rise to fer- 
mentation from excess of sugar. Pills and capsules are not intended for 
children who rarely can swallow them. Prescriptions should be simple and 
if possible contain but one or at most two drugs. Powders made up with 
sugar of milk are mixed with water and given from the teaspoon. Tablet 
triturates form an easy and accurate method of giving drugs. If the child 
is unwilling the medication on the spoon is quickly slipped on to the tongue 
and the spoon held in position well back until swallowing takes place. In 
this way the child cannot regurgate it. 

Begin with small doses in early life and increase if the desired effect 
is not obtained. Heroic doses, however, may be used in emergencies where 
rapid and active stimulation is required. Hypodermatic injection of the 
stimulant is often required to produce physiologic effects. 

Bastedo's rule which was deduced from tables of weights of normal 
children of different ages is as follows : 

Multiply the adult dose by age + 3 

30 

In other words, in writing for thirty doses, for example, a four ounce 
mixture with teaspoonful dose, put down as many minims or grains as 
the age plus three. In writing for fifteen doses (2 oz. mixture) put down 
half as many minims or grains as the age plus three. In the metric system, 
for thirty doses, put down the adult dose X (age -f- 3) X 3, and move the 
decimal point two places to the left. 

This seems to be an advantage over Young's and Cowling's rule and 
furthermore meets with the approval of pharmacologists. 

Castor oil should be administered ice cold on a wet spoon. The taste 

63 



64: 



DISEASES OE CHILDREN". 



of quinine in solution may be disguised with syrup of yerba santa, extract 
of licorice or syrup of wild cherry, but it is not unusual to find children who 
take bitter medication better than adults. Tasteless quinin in the form 
of euquinin, tannate of quinin, or saccharated quinin is now obtainable. 
Sweet chocolate disguises the taste admirably. Opium or its derivatives, with 
the exception of codein, are to be largely avoided. The coal-tar derivatives, 
combined with caffein, are used at times to control pain. They should be 
given in small doses, and not as a routine measure for the control of 
pyrexia. 

The drugs or prejDarations of drugs most frequently used internally 
with the greatest advantage in pediatric practice are : 



Calomel. 

Castor oil. 

Fowler's solution. 

Basham's mixture. 

Bismuth subnitrate. 

Bromides. 

Caseara sagrada. 

Cod-liver oil. 

Strychnin sulphate. 

Digitalis. 

Syrup of iodid of iron. 



Tincture of mix vomica. 

Salicylates. 

Alcohol. 

Potassium iodid. 

Ammonium compounds. 

Atropin. 

Camphor. 

Chloral hydrate. 

Codein phosphate. 

Dover's powder. 

Hexamethylenamin. 



Hydrochloric acid. 

Liquorice powder. 

Phenacetin. 

Rhubarb. 

Salol. 

Iron compounds. 

Asafetida. 

Santonin. 

Aspidium. 

Ipecac. 



TABLE OF AVERAGE DOSAGE. 



Drug. 



Dose, 

Age 

6 mos. 



Dose, 
Age 

2 yrs. 



Dose, 

Age 
3 to 5 yrs. 



Dose, 
Frequency 



Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 



Aconite Tinct. (10 per cent.) . 

Ammonium Chloride 

Ammonium Carbonate 

Ammonium Acetate Sol. 

(Spirits Mindererus) 

Ammonium Aromatic Spts. . 

(Liq. Ammonii Anisatis).. . 
Anitpyrin 



Antitoxin. 
Diphtheritic 

Immunization. . . . 



Pharyngeal Type. 
Laryngeal Type. . 



Arsenic 

Fowler's Sol. 
Arsenitis) . . 



(Liq. Pot. 



Arsenious Acid [ gr 



gtt. | 

gr.i 

gr.i 

gtt. 10 
gtt. 3 
gtt. 1-2 
gr.i 



500 units 



3,000 units 
10,000 
units 



"U 



gtt. * 
gr-l 
gr. I 

dr. \ 
gtt. 5 
gtt. 3 
gr. 1 



500 to 
1,000 units 

5,000 units 
10,000 
units 



"11 



gr- sfo 



gtt. 1-2 
gr. 1-2 
gr. 1-2 

dr. 1-2 
gtt. 10 
gtt. 5 
gr. 2-3 



500 to 
1,000 units 

5,000 units 
10,000 
units 



m,2-3 



gr. 2<to 



q. 2-4 hrs. 
q. 2-4 hrs. 
q. 2-4 hrs. 

q. 4 hrs. 
q. 1-4 hrs. 
q. 1-4 hrs. 
t.i.d. 



Repeat 
or double 
the dose 
in 12 hrs. 
if neces- 
J sary. 



t.i.d. 
t.i.d. 



"12-6 
gr. 12-24 
gr. 12-24 

dr. 3-6 
dr. |-1| 
gtt.30-dr.l 
gr. 5-10 



to effect 



n\, 10, or 
to effect 
gr- 2 Jo-? 3 



GENERAL THERAPEUTICS. 



65 



TABLE OF AVERAGE DOSAGE.— Continual. 



Drug. 




Asafetida, Milk of, by rectum 
only 

Aspidium Oleoresin 

Aspirin 

Atropin 

Basham's Mixture 

Belladonna Tinct 

Beta-naphthol 

Benzoic Acid 

Bismuth Subcarbonate 

Bismuth Subgallate 

(Dermatol) 

Bismuth Subnitrate 

Bismuth Salicylate 

Brandy (Cognac) 

Bromide, Ammonium 

Bromide, Potassium 

Bromide, Sodium 

Bromide, Strontium 

Brown Mixture (see Licorice 
Comp. Mixt.). 

Caffein Citrate 

Calcium Chlorid 

Calcium Sulphid 

Calomel 



dr. 1 



gr. 1 

gr. d 



gtt. jfc 
gr. I 
gr. 1 

gr. 5 

gr. 2-3 
gr. 5-10 

gr- 1-1 • 
gtt. 5-10 



gr. 1-3 



Camphor, Pulverized 

Camphor Spts. 10 per cent.. . . 

Cascara Sagrada, Ext 

Cascara Sagrada, Fluid Ext . . 

Castor Oil 

Cerium Oxalate 

Chalk, Prepared 

Chalk Compound Mixt 

Chloral Hydrate 

Chloroform Spirits 

Cinchona (see Quinin). 

Codein 

Col-liver Oil 

Creosote 

Creosote Carbonate 

Digitalis, Tinct 

Digitalis, Infusion 

Digitalin 

Dover's Powders (see Opium 

Powder of Ipecac). 

Dionin 

Ergot, Fluid Extract 

Ether, Compound Spts. 

(Hoffman's Anodyne) 

Ether, Nitrous Spts. of 

(Sweet Spirits of Niter) 
Ferric Prep, (see Iron.) 



gr- £-: 
gr- i 
gr- sV 



gr. iW 



dr. 1. 



gr. 2 
dr. 1 
gr- \ 
gtt. 1-2 

gr- sV 
dr. i 



gtt. 10 

gr- *h 



gr. A 

gtt. 2-3 

gtt. 2 
gtt. 2 



dr. 1-2 
"l 10 
gr. 1-2 

gr- s oo 
dr. | 
gtt. 1 

gr- h 
gr. 2 
gr. 10-15 

gr. 5-10 
gr. 10-15 
gr. 1-2 
gtt. 10-20 



Dose, Dose, 

Age Dose, Maximum 

3 to 5 yrs. (Frequency.' in 24 hrs. 
Ago 5 yrs. 



gr- -W 
gr. 1 
gr. 2 V 
gr. i-1 

gr- I 
gtt. 5 

gr.* 

gtt. 5. 
dr. 1-2 
gr- 1-2 
gr. 3 
dr. 1 
gr. 1-2 
gtt, 2-3 

gr. -£a 
dr. | 

gtt. 1-2 
gtt. 1-2 
gtt. 1-2 
dr. | 

gr. T l„ 



gr- •.".-, 
gtt. 5 

gtt. 5 

gtt. 5 



dr. 1-2 
n\,30 

gr. 3-5 

gr- 200 
dr. 1 
gtt. 2-5 
gr. 1 
gr. 3-5 
gr. 15-30 

gr. 5-10 
gr. 10-30 
gr. 2-3 
gtt. 20-30 



gr. 5-8 



gr. i 
gr.2 

gr- i 1 ,, 
gr- £-2 

gr- I 
gtt. 5-10 
gr. 1-2 
gtt. 5-10 
dr. 1-4 
gr. 2-3 
gr. 5-8 
dr. 1-2 
gr. 2-3 
gtt. 5-10 

gr- A 
dr. 1-2 
gtt. 2-3 
gtt. 2-3 
gtt. 2-3. 
dr. 1-3 
gr. rkn 



gr. A 
gtt. 10-15 

gtt. 10 

gtt. 10 



pro doso 
once 
q. 4. hrs 
q. 4 hrs. 
t.i.d. 
q. 4 hrs. 
t.i.d. 
q. 4 hrs. 
p.r.n. 

p.r.n. 
p.r.n. 
p.r.n. 
q. 3 hrs. 



4 hrs. 



q. 4 hrs. 
t.i.d. 
t.i.d. 
in divided 

doses 
q. 2-4 hrs 
t.i.d. 
t.i.d. 
t.i.d. 
pro doso 
t.i.d. 
q. 4 hrs. 
q. 3 hrs. 
q. 4 hrs. 
q. 4 hrs. 

q. 4 hrs. 
t.i.d. 
t.i.d. 
t.i.d. 

q. 4 hrs. 

t.i.d. 
p.r.n. 



t.i.d. 
t.i.d. 

p.r.n. 



dr. 2 

n\, 10-30 
gr. 15-20 

gr- 5V 
oz. £ 
in, 5-10 
gr. 3 
gr. 5-10 
dr. 2-3 

dr. 2\ 
oz. I 
gr. 5-15 
dr. 1-oz. \ 



gr. 25-40 



gr.2 
gr. 4-6 
gr- AH 
gr- 1-2 

gr- 1-1 
nt 10-30 
gr- 2-5 
dr. I 
oz. I 
gr. 5-10 
gr. 20-30 
oz. 1 
gr. 5-10 
dr. \ 

gr- 1-1 
oz. \-\ 
gtt. 5-10 
gtt. 5-10 
gtt. 5-15 
dr. 3-oz.l 
gr- ,\, 



gr. A 
dr. \ 

dr. I 



q 1-2 hrs.. dr. \\ 



66 



DISEASES OF CHILDREN. 



TABLE OF AVERAGE DOSAGE.— Continued. 



Drug. 



Dose, 

Age 

6 mos. 



Dose, 

Age 

2 yrs. 



Dose, 

Age 

3 to 5 yrs. 



Dose, 
Frequency. 



Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 



Fluoroform (2.8 per cent, sol.) 
Fowler's Sol. (see Arsenic Liq. 
Potass.). 

Glauber's Salts 

Glonoin (Nitroglycerin) 



gtt. 1 



Glonoin (Spts. of) 

Guaiacol Carbonate 

Heroin Hydrochlorid 

Hexamethylenamin (Urotro- 

pin) 

Hoffmann's Anodyne (see 

Ether Spts. Comp.). 
Hydrochloric Acid, Dilute .... 

Hyoscyamus Tinct 

Hydrargyrum (see Mercury). 
Iodid, Sodium, and Potassium. 

Iron. 

Iron, Oxid Saccharated 

Ferric Chlorid, Tine 

Liq. Ferri et Ammonium Ace- 

tatis (see Basham's Mixt.). 
Soluble Citrate of Iron 

(Ferri et Ammonii Citras) . . 
Syrup of Iodid of Iron 



gr- ¥<b 

gtt. i 

gr. I 
gr. tU 

gr- \ 



gtt. \ 
gtt. | 

gr. 1 



gr. 1 

"I 2 



gr. I 



Pyrophosphate of Iron, (Solu- 
ble) Elixir of 

Reduced Iron 

Liq. Ferri Peptonati (N. F.). . 
Ipecac, Wine of (Emesis) 



Ipecac, Syrup of (Expectorant) 

Jalap, Powdered 

Licorice Compound Mixture 
(Brown Mixture) 

Liquorice Compound Powder. 

Magma Magnesia (N. F.) Milk 
of Mag 

Magnesium Citrate (Liq. Mag- 
nesia Citrate Effervescent). . 

Magnesium Sulphate 

Male Fern, Oleoresin (see 
Aspidium). 

Mercury Bichlorid 

Mercury Mild Chlorid (Cal- 
omel) 



Mercury Biniodid 

Mercury with Chalk 

Powder) 

Morphin Sulphate 



(Gray 



"l 5 
gtt. 5 

gtt. 2 
gr. h 

gtt. 15 
gr. 10 

nilO 

oz. \ 
gr. 15 



gr- 2 U 
gr- iV- 
gr- Tso 
gr-i 



gtt. 2 



gr. 30 



gtt. \ 
gr. 1 
gr. sV 

gr. 1 



gtt. 2 
gtt. 2 

gi.2 



gr. 2 
"11 



gr. 1 
gtt. 5 



"Hi 5 
gr. \ 
"110 
dr. \ 

gtt. 3 
gr. 2 

gtt. 20-30 
gr. 20 

dr. \ 

oz. 2 
gr. 30 



gr. l-l 

gr- sV 

gr- I 
gr. 5 V 



gtt, 6. 

dr. 1 
gr- nU 

to 

gtt. 1 
gr. 5 
gr- A 

gr. 2-5 



gtt. 5 
gtt. 3 

gr. 3 



gr. 5 

m,3 



gr. 3 
gtt. 5-10 



TTV15 
gr. 1 
m,30 
dr. ^-1 

gtt. 5 
gr. 3 

gtt. 30-40 
gr. 40-dr. 1 

dr. 1 

oz. 4 
gr. 60 



gr. to 
gr- 1-2 
gr- sV 



gr. 



q. 2 hrs. 



pro doso 
q. 2-4 hrs. 

q. 2-4 hrs. 
q. 4 hrs. 
q. 4 hrs. 

t.i.d. 



t.i.d. 
t.i.d. 

t.i.d. 



t.i.d. 
t.i.d. 



t.i.d. 
t.i.d. 



t.i.d. 
t.i.d. 
t.i.d. 
q. £ hrs. 
to effect 
q. 4 hrs. 
once 

q. 3 hrs. 
bed time 

t.i.d. 

in a. m. 
in a. m. 



t.i.d. 

in divided 

doses 
t.i.d. 

t.i.d. 
p.r.n. 



gtt. 48 



dr. 1-3 



gtt. 4-8 
gr. 20 
gr- A 

gr. 5-15 



gtt. 15 
gtt. 10 

gr. 5-10 



gr. 3-15 

rri 10 



gr. 3-10 

gtt. 15- 

dr. § 

w\, 45 
gr. 3 
dr. 1J 
dr. 3 

dr. h 
gr. 3 

dr. 2-oz. i 
dr. 1-1 

dr. 3 

oz. 6 
dr. 1 



gr- ^s 
gr. \-2 



gr. \ 

gr- 3 

gr. A 



GENERAL THERArEUTICS. 



67 



TABLE OF AVERAGE DOSAGE.— Continued. 



Drug. 



Dose, 

Age 

6 mos. 



Dose, 

Age 
2 yrs. 



Dose, 

Age 

3 to 5 yrs. 



Dose, 
Frequency. 



Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 



Niter, Sweet Spirits of (see 
Ether Spts. Nitrous). 

Nitroglycerin (see Glonoin). 

Nux Vomica Tinct 

Novaspirin 

Opium Tinct. (Laudanum) . . . 

Opium, Camphorated Tinct.. . 

Opium, Powder of Ipecac and 
(Dover's Powder) 

Peppermint Water (Aqua 
Mentha Piperita) 

Pepsin Powdered 

Pepsin Essence of (N. F.) .... 

Phenacetin (Acetphenetidin). . 

Phosphorus 

Syr. Calcii Lactophos 

Phosphoric Acid Dil 

Syr. Hypophosphites 

Potassium Acetate 

Potassium Bitartrate 

Potassium Bromid 

Potassium Citrate 

Potassium Chlorate 

Potassium Iodid (Expector- 
ant) 

Potassium Iodid (as Anti- 
syphilitic) 

Quinin, Sulphate and Bisul- 
phate 

Rhubarb Powdered 

Rhubarb Syrup Arom 

Rhubarb and Soda Mixture . . 

Rhubarb and Anisated Mag- 
nesia Pulv. (N. F.) 

Salicin 

Sodium Salicylate 

Methyl Salicylate 

Aspirin 

Oil of Wintergreen 

Salol 



gtt, 1 
gr.l 



gtt. 3-5 
gr. i-i 

dr. | 
gr. 1 

gtt. 20 
gr-l 

gtt. 10 
gtt. 1-2 
gtt. 15 
gr. 1 
dr. § 
gr. 1-3 
gr. 1 
gr-l 

gr- I 

gr. 1 

gr-l 
gr. 1 
gtt. 15 



gr. 3 



gr. 1 
gtt. 1 



.Santonin 

Serum Antidiphtheritic 

Antitoxin). 
Serum Antimeningitic. . 



(see 



15 c.c. 



Sodium Benzoate. . . . 
Sodium Bicarbonate. 

Sodium Bromid 

Sodium Iodid 

Sodium Phosphate. . . 
Sodium Sulphate. . . . 
Spartein Sulphate . . . 
Strophanthus Tinct. . 



gr. 


1 


gr. 


2 


gr. 


1-3 


gr. 


1 


gr- 


15 


gr. 


A 


gt< 


. i 



gtt. 2 
gr. 1-2 
gtt. 1-2 
gtt, 15 

gr. I 

dr. 2 
gr. 2 
gtt. 30 
gr. 1 

gtt. 30 
gtt. 5 
gtt, 30 
gr. 3 
dr. 2 
gr. 3-5 
gr. 2 
gr. 2 

gr-l 
gr. 2 

gr. 1-2 
gr. 3 
dr. 1-2 
dr. |-1 

gr. 5-10 
gr. 1-2 
gr. 2 
gtt. 3 
gr. 1-2 
gtt. 3 
gr. 1-2 
gr. J 



15 c.c. 

gr. 2 
gr. 3 
gr. 3-5 
gr. 2 
gr. 30 
gr. 30 
gr- ,>V 
gtt. 2 



gtt. 3-6 
gr. 3-5 
gtt. 2-3 
gtt. 20 

gr. 1-2 

dr. 4 
gr. 3 
dr. 1 
gr. 2 

dr. 1 
gtt. 10 
dr. |-1 
gr. 5 
dr. 4 
gr. 5-8 
gr. 5 
gr- 3 

gr. 1 



gr. 3 



2-3 
5 

1-2 



dr. 1-2 

gr. 10-20 
gr. 2-3 
gr. 3-5 
gtt. 5 
gr. 3-5 
gtt. 5 
gr. 2-3 
gr-l 



30 c.c! 

gr. 3 
gr. 5-10 
gr. 5-8 
gr. 3 
gr. 60 
gr. 60 
gr. rV-J 
gtt. 3 



t.i.d. 
q. 4 hrs. 
p.r.n. 
q. 4 hrs. 

p.r.n. 

t.i.d. 
t.i.d. 
t.i.d. 
q. 4 hrs. 

t.i.d. 
t.i.d. 
t.i.d. 
t.i.d. 
once 
q. 4 hrs. 
q. 4 hrs. 
t.i.d. 

q. 2-4 hrs 

t.i.d. 

q. 4 hrs. 
t.i.d. 
t.i.d. 
t.i.d. 



b 


i.d. 


q 


3 hrs. 


q 


3 hrs. 


q 


2-3 hrs 


q. 


4 hrs. 


q- 


2-3 hrs 


t. 


.d. 


q- 


4 hrs. 



daily for 4 
hrs. 



days 



q 

p.r 

q 

t.i.( 
pro 
pro 
q. 3 
q.4 



4 hrs. 

d. 
doso 
doso 

hrs. 
hrs. 



gtt 5-15 
gr. 15-20 
gtt, 10 
dr. 1-2 

gr. 1-5 

oz. 1-1| 
gr. 5-10 
dr. 3 

gr. 4-8 

dr. 3 
dr. | 
dr. 3 
gr. 15 
oz. | 
gr. 25-40 
gr. 15-30 
gr. 10 

gr. 10 

gr. 10 

gr. 5-15 
gr- 15 
oz. | 
oz. I 

gr. 40 
gr. 24 
dr. I 
n\, 20-30 
gr. 15-20 
gtt. 30 
gr. 10 
gr- 1-2 



pro doso 



gr. 
gr. 
gr. 

gr- 
dr. 
dr. 
gr. 
gtt. 



10-15 
20-30 

25-40 
5-10 



1 
1-3 

4 

'l2 



6$ 



DISEASES OF CHILDREN. 
TABLE OF AVERAGE DOSAGE.— Continued. 



Drug. 



Dose, 

Age 

6 mos. 



Dose, 

Age 

2 yrs. 



Dose, 

Age 

3 to 5 yrs. 



Dose, 
Frequency. 



Dose, 
Maximum 
in 24 hrs. 
Age 5 yrs. 



Strychnin Sulphate. 

Tanalbin 

Tannigen 

Tartar Emetic 

Terpin Hydrate 
Thyroid Ext. Desic. 

Thymol. 

Urotropin 

Veronal 

Whisky 



gr. *h 
gr. 1 
gr. 1 
gr. ah 



gr-soo-ii. 



-1 



gr 

gr. i 
gtt. 10 



gr. 
gr. 
gr. 
gr. 
gr, 
gr. 
gr. 
gr. 
gtt. 10-20 



4 

1-2 
1-2 

1 
1 



gr. too 
gr. 5 
gr. 5 
gr. i^o 
gr. h 
gr. 3 
gr. 2-5 
gr. 2-5 
gr. 1-2 
gtt. 30-40 



q. 4 hrs. 
q. 2 hrs. 
q. 2 hrs. 
q. 4 hrs. 
q. 3-4 hrs 
t.i.d. 
t.i.d. 
t.i.d. 
once 
q. 4 hrs. 
or oftener 



S A - 2 5 

dr. 1 
dr. 1 
gr- is 
gr. 3 
gr. 9 
gr. 15 
gr. 5-15 
gr. 2 
oz. \ 



Introductory Remarks. 

The treatment of diseases in children requires a thorough knowledge 
of all measures, besides drugs, that may be used for alleviation or cure. If 
the medical attendant places sufficient dependence upon such measures as 
hydrotherapy, fresh air, and diet he will be inclined to order fewer drugs 
or only such as are still indicated. Familiarity with the details of the gen- 
eral therapeutics of childhood will make him resourceful and capable of 
adapting his treatment to the particular surroundings and needs of the 
child. 

The physician should take into consideration the general develop- 
mental condition of the child, its usual habits and the intelligence of those 
who will carry out his orders. Orders should always be specific, and are 
preferably written out in detail, as a mother's anxiety for her sick child 
may lead to misunderstandings which may prove serious. 

While many of the diseases are self -limited, and recoveries are generally 
speedy because of the recuperative powers in early life, still the practitioner 
should always alleviate distress and hasten complete recovery by the proper 
use of drugs and other medical measures. 

Prescriptions should be simple, containing only one or two ingredients, 
and made as palatable as possible without endangering the child's diges- 
tion. Glycerin and saccharin will serve this purpose and are to be preferred 
to the syrups or sweet elixirs which so readily cause fermentation. Medi- 
cation and other measures for relief should be so arranged that the child 
will not be continually disturbed; for rest is an important adjunct in all 
cases. 



GENERAL THERAPEUTICS. 69 

In the practice of pediatrics preventive treatment should be con- 
sidered first, last, and all the time, for it is only thus, through the saving 
of lives and the rearing of healthy children who can later become healthy 
parents, that infant mortality can really be reduced. 

Psychotherapy. 

The influence that can be exerted for good or evil, over the receptive 
mind of a child has been well emphasized in recent years by psychologists 
and physicians. Often a good part of a physician's success in handling 
little patients is due to his knowledge and interest in their mental processes. 
He learns to take advantage of their susceptibility to conviction, to sugges- 
tion, or of their pride, and control is thus easily acquired. The harmful in- 
fluence of certain members of the family may prevent good results, especially 
in neurotic diseases, until the child is removed to different surroundings. A 
stranger often has better control over the sick child than its own mother. 
Time spent in studying the mental attributes of a seemingly incorrigible 
patient is well spent, for almost without exception the maturer mind con- 
quers by persistence tempered with kind indifference. 

In older children hysterical manifestations can be controlled by the 
forceful attendant and their repetition prevented by a radical change in 
environment and daily routine. Such conditions as enuresis we have often 
been able to cure by psychic influences depending mainly upon the child's 
pride. Another factor often lost sight of in this connection is the influence 
of associates. Through a proper selection of playmates in age and tem- 
perament, much may be done from a psychic standpoint. 

Aerotherapy. 

It is a deplorable fact that there is any need of emphasizing the use 
of fresh air in the treatment of disease. The laity, however, have been so 
imbued for years with the idea that colds are the result of cold air, and 
that sickness in the house demands warm rooms that the practitioner, in 
spite of his better judgment, often acquiesces in these notions. Among 
the more intelligent of our population the need of an outdoor life is begin- 
ning to be appreciated, and it only demands thai orders for sufficient fresh 
air be given with a spirit of conviction that the method is a right and just 
one, to gain the cooperation of the parents. The harmful influence of 
impure air or a paucity of fresh air is no better illustrated than by com- 
paring the poor results formerly obfained in institutions and hospitals for 
children, even when skillful nursing was at hand, to the good results 
obtained with abundance of fresh air. 



TO DISEASES OE CHILDREN. 

Aerotherapy, or an abundance of pure fresh air, should be arranged 
for in every sick-room as well as in the nurseries of healthy children. In 
respiratory diseases accompanied with fever the good effects of cool fresh 
air are particularly noticeable. 

In convalescence a change to the country or seaside, where ozone is 
abundant, will do more than a course of iron tonics or artificial stimulants. 
The summer diarrheas are often promptly alleviated by a sojourn in a cool 
and dry atmosphere. 

Hydrotherapy. 

The use of water is safer and often more effective than the use of 
antipyretics in reducing temperature. It also has a tonic effect instead of 
the depressing effect of antipyretic drugs. A warm bath given to a child 
conserves the body heat, is sedative in its action, and increases the perspir- 
ation. On the other hand, cold baths decrease the body heat and leave a 
stimulating and eliminative action. 

Sponge Baths. — Cool sponge baths with or without alcohol are 
effectual and usually agreeable to children when their tempearture is high. 
Cold baths or cold packs are rarely necessary and may be productive of con- 
siderable shock. Equal parts of alcohol and water at 90° F. are applied to 
the child lying in a woolen blanket; gentle friction causes air evaporation 
and reduction of temperature. While the bath is in progress ice cold cloths 
may be placed on the forehead and head of the child. 

Sheet or Bed Baths. — Eubber sheeting is spread on the bed and a 
soft sheet or blanket is wrung out of water at 90° to 100° F. The patient 
is wrapped in this and cold applications at 60° F. placed to the head. In 
older children water at a lower temperature, 70° or 80° F., may be sprinkled 
over the sheet to effect a further reduction of body heat. The patient 
should remain in such' a bath for about twenty minutes and it may be 
repeated several times during the day if the necessity arises. 

Ice Cap. — -For persistent high temperature with delirium an ice cap 
may be placed at the nape of the neck or on top of the occiput. The thin 
rubber ice bladders are half filled with small pieces of cracked ice and all 
air is expelled. They should be used only intermittently, and a trained 
attendant should be present, as all cases do not respond well to its applica- 
tion. 

Ice Poultice. — Small pieces of cracked ice are mixed with an equal 
portion of bran or sawdust and wrapped in oil silk or rubber sheeting in 
such a way as to prevent leaking. This may be used as the ice cap above, 
but has the advantage that it may be improvised at home. 

Compresses. — Compresses wrung out of water varying from 80° to 



GENERAL THERAPEUTICS. 71 

100° F. according to indications may be applied to the neck in tonsilitis, 
over the abdomen for enteralgia and about the chest in cases of pneumonia. 
When used on the chest they should be divided into two portions, one for the 
left and one for the right, so that they may be removed with as little dis- 
turbance as possible to the patient. They may also be applied to the 
exposed part of the chest in one piece and tucked around as far as possible 
without disturbing the child. 

Warm and hot baths are agreeable, soothing, and sedative. The 
temperature of the body is reduced and the relaxation which follows pro- 
motes sleep and diuresis. A warm bath is given at a temperature of 85° to 
98° F., -while a hot bath may range to 110° F. The warm bath is suitable 
for the reduction of temperature, and should last from five to fifteen 
minutes. Cool applications may be placed upon the head if the pyrexia is 
particularly high. Hot baths should be given to asthenic infants when the 
temperature is high or subnormal. The addition of mustard is useful, 
especially if there are evidences of shock or collapse. The baths should be 
short, not exceeding over five minutes in duration. The patient should be 
wrapped in warmed woolen blankets and allowed to rest, unless free per- 
spiration is indicated as in nephritis, when hot drinks may also be given. 
A hot pack is useful in nephritic or uremic cases. The child is 
wrapped in a woolen blanket wrung out of water at 110° F. and covered 
with another dry one, beneath which are placed numerous hot-water bags. 
Hot drinks are offered. The pulse should be watched and the child 
removed when a free perspiration is induced. 

A hot-air bath is given by introducing hot air from a croup kettle 
under the blankets of the bed for about half an hour or until free diaphoresis 
is obtained. 

Special Baths. 

A brine bath is given by adding a half-pound of sea salt to six gallons 
of water at a temperature of 105° F. and gradually reducing to 90° F. 
Gentle friction should be kept up throughout the bath, which should not 
last longer than fifteen minutes. It is indicated as a stimulating hath for 
undernourished, poorly developed children, especially those with tuberculous 
tendencies. 

The addition of bran, starch or bicarbonate of soda in Luke-warm water 
will serve to allay the irritation of certain skin diseases, as urticaria. A 
quarter of a pound of soda is sufficient for a six-gallon hath. When a bran 
hath is given half a pint of bran in a cheesecloth hag is drawn through the 
water. For the starch bath a quarter of a pound, or half a cup, of raw 
starch is slowly dissolved in the water. 



72 DISEASES OF CHILDREN. 

A soothing bath which will promote sleep in nervous, irritable chil- 
dren is made by the addition of fifteen drops of pine-needle oil to the water 
at 110° F. Xo friction should be made. 

A mustard bath is prepared by immersing an ounce of mustard in a 
cheesecloth or muslin bag in the water, usually at a temperature of 105° F. 
Cold compresses are applied to the head, and the body is gently rubbed. 

Carbonic acid baths (artificial Xauheim baths) may be prepared by 
the addition of chemicals or specially prepared Triton salts to the water, 
but the evolution of the gas is somewhat uncertain and irregular. The gas 




Fig. 22. — Method of giving alcohol sponge bath. 

may be generated by the action of bicarbonate of soda and hydrochloric acid 
in a porcelain-lined tub. The acid being diffused through the water after 
the soda has been dissolved. Another method has recently been placed on 
the market which is dependent upon the use of a specially constructed mat 
through which the gas is allowed to flow from a cylinder of the compressed 
gas. The flow of gas is greater, it is more evenly distributed through the 
bath and it can be regulated. It is certainly preferable to the older 
methods for home use if the baths are likely to be needed for a long period 
of time. The bath is given at 90° to 95° F. for five minutes and is followed 



GENERAL THERAPEUTICS. 73 

by gentle friction and rest in bed for several hours. These baths must be 
given at least three times a week for several months to produce permanently 
good effects. The baths are indicated in the convalescent stages of 
myocardial diseases. 

The Nasopharyngeal Toilet. 

The nasopharyngeal toilet, as advocated by Caille, is a valuable pro- 
phylactic measure in diseases affecting or emanating from the respiratory 
tract, and is an effective adjunct in promoting a healthy condition of the 
nasopharyngeal mucuous membrane in many febrile diseases. 

Method. — The method consists in slowly pouring into each nostril, 
by means of an ordinary teaspoon, a drachm of normal salt solution while 
the child lies with his head tilted back over a pillow and his mouth open. 
If gentleness is combined with tact when the measure is first attempted, 
the child soon learns that the method is not painful nor disagreeable. Tt 
can be used to advantage in such infectious diseases as diphtheria and 
scarlatina, and before and after operations upon the nose and throat, as 
in adenectomy and tonsillotomy and retropharyngeal abscess. 

Lavage. 
(Stomach Washing.) 

This is a useful practice, but one which is often much abused. It is 
indicated as an initial procedure for persistent vomiting, especially in 
summer diarrhea, in cases of chronic gastrointestinal indigestion, acute 
gastritis, poisoning, in persistent vomiting, and preceding certain operative 
procedures as intestinal obstruction. Repeated stomach washing is to be 
deprecated. If the symptoms persist it is usually an indication that the 
dietary regulation is faulty. 

The apparatus used is made with a soft-rubber catheter, Xo. 1 2 
American, attached by means of a piece of glass tubing to another length 
of rubber tubing at the end of which is placed a small funnel. The catheter 
is introduced into the esophagus without any difficulty and with little dis- 
comfort to the infant. A warmed fluid, which may be either a normal 
saline solution, or contain bicarbonate of soda (a dram to the pint), or 
boric acid 2 per cent., is used in amounts depending upon the age ami 
development of the child (see Chap. Y). AVhen the stomach is full this 
will be noted in the funnel, which is then depressed and the contents 
siphoned off. This process is repeated until the return flow is clear. The 
preferable method is to hold the child upright in the nurse's lap, the head 



74: 



DISEASES OF CHILDREN. 



being slightly inclined forward; if for any reason this is contraindicated 
the infant may be placed on its side, but this position requires more 
dexterity than the upright. 

Enteroclysis. 
Enterocylsis is a measure which can readily be used in infants and 
children. No special apparatus is required as in venous infusions or hypo- 
dermoclysis. In the latter, surgical cleanliness must be strictly observed, 




Fig. 23. — Illustrating technic for hypoderinoclysis. 



and it is difficult to carry out the technic, without trained assistants, outside 
of a hospital. Flushing the colon not only clears: out the lower intestinal 
tract of deleterious material, but it stimulates renal secretion, thus promot- 
ing the excretion of toxic products. If there is high temperature this will 
be reduced and thirst assuaged. The absorption of the fluid increases the 
blood pressure, and by eliminating poisonous products indirectly assists in 
renewing the condition of the blood itself. 

Method. — A soft-rubber rectal tube is attached to the end of a foun- 
tain bag into which has been poured a saline solution made by dissolving 
two teaspoonfuls of salt to two quarts of water at 110° F. The bag should 



GENERAL THERAPEUTICS. 



75 



be hung about three feet above the patient and the water allowed to flow 
slowly into the gut. If the intestine is irritable the pressure maj be lowered 
so that the water will flow very slowly after the bowel has been emptied. 
Fluids will not usually penetrate beyond the ileocecal valve, but the entire 
intestinal tract will be stimulated to greater activity by the process. 

In a series of radiographic studies of the colon and sigmoid flexure in 
the infant, Chapin showed there were remarkable variations both in form 
and situation. From these and other studies it has been proven that it is 
rarely, if ever, possible to pass the tube through the sigmoid flexure. In 
flushing the bowel it is only necessary to pass the tube through the sphincter 




Fig. 24. — The large intestine of an infant, showing curve of sigmoid flexure. 



and a few inches into the rectum. The fluid will then by reversed peristalsis 
reach the ileo-cecal valve. It is unnecessary and even harmful to try and 
pass the tube too far. 

In place of the saline solution it is often of advantage to use a bland 
soothing preparation, such as starch water, or, on the contrary, soap suds 
may be necessary if the intestine is inactive. 

The indications for flushing or irrigation of the bowel are the removal 
of the putrescent material, as in enteritis and cholera infantum, and to 
assist elimination in the infectious diseases, such as typhoid and scarlet 
fever. It is also of distinct value in septic conditions and nephritis. In 
conjunction with baths it may also be used to reduce high temperatures, 
thus counteracting the harmful effects produced by the loss of fluids in the 
tissues. Once a day is usually sufficient. The mucous membrane is 
rendered irritable by too frequent irrigations. 



76 DISEASES OE CHILDREN. 

Gavage. 

Gavage, or forced feeding by the stomach-tube, is accomplished with 
practically the same kind of apparatus as that used for lavage, that is, 
a No. 12 American, soft-rubber catheter, a piece of tubing and an eight- 
ounce funnel, preferably of glass. The upright or the prone position, with 
the child lying on its back, may be selected. With infants no mouth-gag 
is required. In older children a mouth-gag, well protected by pieces or 
rubber to prevent laceration of the gums, will be necessary. Before intro- 
ducing the food for the first time it is better to do a preliminary stomach 




Fig. 25. — Enteroclysis ; position of the patient for bowel irrigation. 

washing. The food is allowed to flow slowly into the stomach, and when 
the desired amount has been introduced the catheter should be quickly with- 
drawn, the tube first being firmly pinched to prevent regurgitation and the 
entrance of any of its contents into the larynx. The infant should then be 
placed in bed and not disturbed, as in highly irritable conditions the food 
might be regurgitated. 

The indications for gavage are the feeding of premature or asthenic 
infants who are unable to otherwise take their food, cases of habitual or 
obstinate vomiting in which the infants, as shown by Kerley, may vomit 



GEXEEAL THEKArEUTlCS. 



77 



the food when swallowed, but retain it when given by the tube. Occasion- 
ally following intubation or operations on the esophagus, feeding by gavage 
is necessary. During meningitis or conditions in which there is coma, 
forced feeding may be indicated; as rectal feeding, except for a day or two, 
is of little value in early life. 

The food used may be breast milk, full strength or diluted, modified 
or peptonized cow's milk, plain or dextrinized gruels. The amounts should 
be somewhat below the usual requirements and the periods of feeding- 
lengthened. Care should be taken that the food is sufficiently warmed 
when it enters the stomach, as a luke-warm temperature is apt to induce 
vomiting. 



i 


s % 


Jp\ 


jf m m* V I '' ! 




If 


i 



Fig. 26. — Position and apparatus for gavage. 

Rectal Feeding — Nutrient Enemata. 

Eectal feeding is rarely of service except for temporary use, as very 
little nutriment is absorbed. It may be possible to check body waste by 
this means, but we have never seen increase in weight when this was the 
only form of feeding. It is indicated in cases of cyclic or incessant vomiting 
or where there is an inability to swallow, in certain operative cases and 
when the food is not tolerated by the stomach. 

Method. — The rectum should be cleansed with a bland enema, as 
saline solution, and an interval of at least a half-hour should be allowed 



78 DISEASES OE CHILDREN. 

before injecting the food into the rectum. The child is placed on his back 
or left side with the thighs well elevated. The prepared food is allowed to 
flow into the rectum from an ordinary fountain bag to the end of which has 
been attached a small-sized colon tube or large-sized catheter. If the anus 
and tube are well anointed with vaseline the tube may be advantageously 
passed well up into the colon. If this is slowly and gently done, peristalsis 
will not be excited, and the contents of the bag held just high enough to 
permit a flow will be more apt to be retained. 

Infants will retain about two to six ounces, young children four to ten 
ounces. These enemata may be given three or four times in the twenty- 
four hours. Smaller amounts are always better tolerated and retained than 
larger quantities. When the rectal tube is withdrawn the buttocks should 
be pressed together, the child still retaining the recumbent posture. The 
fluids that may be -used are peptonized or pancreatinized milk, eggs, albumin 
and gruels, or a combination of these. Occasionally stimulants or other 
drugs may be added to the food. 

Vaccine Therapy. 

The pathogenic action of any organism is almost entirely dependent 
upon the toxins which it produces. The most important feature of the 
bacterial toxins is its relation to immunity. An animal immunized to the 
action of a toxin is also protected against the pathogenic action of the 
bacterium which produces it. The toxins fall into two main groups : the 
extracellular soluble toxins (exotoxins) and the intracellular insoluble 
toxins (endotoxins). 

The exotoxins are given off in a free state when the bacteria are grown 
in a suitable medium, and can easily be separated by means of a porcelain 
filter. They are not formed by all pathogenic bacteria. The most impor- 
tant examples of toxins belonging to the exotoxin group are the Bacillus 
diphtherias and Bacillus tetani; and it is in this group that the antitoxins 
are most easily developed and are most potent. 

The group of the endotoxins is a much larger one, and it is with this 
type that a great deal of experimentation with the vaccines has been under- 
taken. The endotoxins are present in the bodies of bacteria, whether the 
latter have been killed by heat, by antiseptics, or by drying 1 . This whole 
subject is further complicated by the fact that when bacteria are injected 
into a living animal they meet with resistance on the part of the host, and 
under these circumstances may produce protective substances which are 
toxic. This may in part account for the disappointing results which so 
frequently follow the use of a vaccine. 



GENERAL THERAPEUTICS. ?9 

All individuals have a certain amount of natural resistance to infection, 
and the effort with vaccines is to increase this resistance. The protective 
substance which exists in the blood is called opsonin, and its function is the 
preparation of bacteria for ingestion by the leukocytes. During an infec- 
tive process the amount of opsonin is below normal. Dead bacteria from a 
culture of the infective organism are injected into the infected individual 
for the purpose of increasing the opsonins to normal or above normal, and 
by thus rendering the blood rich in protective substance to hasten immunity. 
Immediately after injection resistance is on the whole lowered, and this is 
known as the negative phase, following which the resistance increases. In 
order to avoid giving a second injection during this negative phase Wright 
devised a method for measuring the opsonic power of the blood. This 
method is cumbersome, difficult and at best uncertain; and at the present 
time has been largely given up. In its place has been substituted a careful 
study of the clinical symptoms, and this method perhaps given sufficient 
indications for the timing of the dose. In any case it is probable that the 
importance of the so-called cumulative negative phase has been exaggerated. 
Still it must be confessed that there is very little agreement among those 
who are using vaccines as regards either the size or the spacing of the dose. 

The preparation of a vaccine is comparatively simple. The organism 
to be used is grown in pure culture. The culture is taken up in physio- 
logical salt solution, which is shaken until evenly distributed, after which 
it is standardized so that each c.c. contains a definite number of bacteria. 
These bacteria are then killed by heating to 60° C. for one-half hour, and 
0.5 per cent, of carbolic acid is added as a preservative. 

In children a smaller close is given than to adults, and as usual this 
is based on age. The dose varies, however, according to the organ ism 
injected. It might be added that larger doses are rarely followed by dis- 
turbing symptoms, and there are indications that the present dosage of 
vaccines is too small. 

Unfortunately the statistics as regards vaccines are not very reliable. 
The occasional brilliant result in an isolated case may be due to the part 
nature plays in affecting a spontaneous cure, while on the other hand where 
no results are obtained there is nothing to publish. Also it is certain that 
overzealousness in trying a new remedy has frequently eclipsed the better 
judgment of the observer. 

Scarlet Fever. — In scarlet fever the Russians have apparently 
achieved remarkable results by preventive inoculations with a vaccine made 
from a bouillon culture of streptococcus isolated from a person ill with 
scarlet fever, and killed by heating to 00° 0. These vaccines were used in 



80 



DISEASES OF CHILDREN. 







Fig. 27. — Exercises for developing children: (a) narrow flat chest in a mouth 
breather; (b) showing winged scapula? and curvature; (c) and (d) corrective 
exercises. 



GENERAL THERAPEUTICS. 81 

Russian villages in scarlet fever epidemics in which from 15 to 5T per cent, 
of the uninoculated were stricken with the disease. Of those who had 
received three injections of the vaccine none were affected; of 2,084 who 
had received two or more vaccinations, only two were attacked; of 2,73? 
others who had received only one injection of the vaccine, forty-one were 
attacked. Most of those cases who had received vaccine treatment ran an 
exceedingly mild course. The immunity following three injections is 
supposed to last about one and one-half years. 

These figures are not only important from a prophylactic standpoint, 
but also serve as a strong indication of the etiological cause of scarlet fever. 

Typhoid Fever. — Available statistics indicate that prophylactic vac- 
cination against typhoid is an invaluable measure. The duration of the 
immunity conferred is not as yet determined, but it is probably about three 
years. The reaction to this vaccination is only occasionally quite severe; 
there being malaise, fever and soreness at the point of injection. 

As regards vaccination during the course of the fever itself there is a 
great difference of opinion, the consensus of opinion being that it is of no 
value. However, there is reason to think that the dose has been much too 
small and perhaps the results would have been better if 200,000,000 or 
300,000,000 bad been used instead of the usual dosage of 30,000,000 or 
50/100,000. 

Septicemia and Septicopyemia. — ■ Its treatment with autogenous 
vaccines has seemingly been of value in some cases. Certainly a blood 
culture should be made in all of these cases and the effects of a vaccine tried. 

Pneumonia. — As pneumonia is a self-limiting disease it is difficult 
to draw any conclusions as to the value of the vaccine treatment. Little or 
no attempt has been made to treat children in this manner. There are 
several reasons for this, the chief of which is the varied infective agent of 
the pneumonia, which entails the considerable delay of making an auto- 
genous vaccine for each case. 

Acute Ulcerative Endocarditis. — If a positive blood culture is 
obtained benefit may be hoped for by the use of an autogenous vaccine. 
About one-third of the cases will show no improvement. Out of six cases 
treated by Wright two were cured, one improved and three were not affected 
one way or the other. 

Adenitis. — The eases of acute adenitis are too few to allow of any 
conclusion-. 

In tuberculous adenitis the tuberculin treatment seems to be of some 
value. Tin's is especially true if treatment is begun before the gland begins 
to break down. 



82, 



DISEASES OE CHILDREN. 



Pyelitis and Cystitis. — The result of treatment with vaccines in both 
of these conditions is very good, particularly in colon b. types. The im- 
provement usually begins promptly, the frequent urination, pain, etc., 
disappearing quickly. It is, however, practically impossible to cause a total 
disappearance of the pus and bacilli. 

Vaginitis (Specific). — Hamilton recently published some very grati- 
fying figures as regards the treatment of vaginitis in children, the only 
difficulty being that no one has been able to duplicate them. In other hands 
the vaccine treatment in this condition has proven valueless, or nearly so. 

Furunculosis. — The vaccines are of benefit in this condition. Xo 
other method of treatment will give such satisfactory results, although it 
must be born in mind that for some unknown reason a small percentage of 
cases will not react. 

Acne. — Vaccines will cure a large percentage of these cases when the 
acne bacillus can be isolated. In nearly every other case there will be some 
improvement, but here and there a case will be met with in which the 
vaccine will exert no apparent influence. 

Mastoiditis and Otitis Media. — When other means fail a vaccine 
may be tried. There is much difference of opinion as to whether they are 
of any value, the consensus of opinion apparently being that they do little 
good. 

Nearly all those who have worked with vaccines disagree as to the 
dosage. It would be a distinct advantage if there could be some uniformity 
of dosage, but in examining the literature it is found that one man is treat- 
ing furunculosis with 10,000,000 dead staphylococci while another gives a 
dose of 1,000,000,000. Naturally the question arises as to whether the 
dose which the one man gives is not so large as to actually do harm while 
that given by the other is much too small to be effective. There is the same 
disagreement as regards the spacing of the dose, some giving it every day 
and others every two weeks. For these reasons the following table based on 
work flone under our direction is given as a tentative one: 



Organism 


Dose 


Interval between closes 


Staphylococcus 




250-1,000 million 


Three to seven days. 


Streptococcus 




25 million 


Dailv. 






100 million 


Every fifth day. 


Pneumococcus 




50-250 million 


Two to five days. 




(infant 


10 million) 


In pneumonia smaller doses at 
more frequent intervals should 
be used daily. 


Gonococcus 


Acute, 


5-50 millions 


Every five days. 




Chronic 


50-500 million 




Typhoid bacilli 


Immunity, 


750-2.000 million 


In three doses at ten days in- 
terval. 




Treatment, 


100-250 million 


Every other day. 


Bacillus coli 




10-50 million 


Three to twelve days. 



GENERAL THERAPEUTICS. 83 

Stock vaccines may be used if the diagnosis is established, until such 
a time as is necessary to prepare an autogenous vaccine. It should be born 
in mind, however, that they are not as satisfactory as those prepared directly 
from cultures of the infecting organism. 

Breathing and Resistant Exercises. 

While special physical training is important and often opportune in 
the cure of deformities and badly-developed children, a greater proportion 
of all children need some systematic training in the act of correct breathing 
and instruction as to correct posture. 

The schools in some of the larger cities are making some valuable 
efforts along these lines, through physical directors who have made a study 
of life during the developmental stage. At this time good habits are easily 
inculcated ; later, in adult life, they are brought about only with difficulty 
and the expenditure of valuable time. 

If breathing as an art is taught the child, it will develop its lung 
capacity and supply the proper amount of oxygen to the growing tissues. 
Each breath should be taken in slowly through the nostrils in as large a 
quantity as is comfortable without effort; gradually this amount is in- 
creased as the natural elasticity of the lungs is increased, and in a short 
time, with thought and practice, diaphragmatic breathing becomes the 
natural breathing of the child. 

In the Logi method, the patient lies on the floor upon a sheet, with 
windows wide open and clothing perfectly free. One nostril is closed and 
an inhalation taken and held a few seconds before exhaling through the 
opposite nostril, and this is. repeated several times with frequent pauses for 
rest and diversion. 

The next step is the development of intercostal breathing: later the 
accessory breathing muscles are utilized, and finally the so-called complete 
breathing is perfected. The best results are obtained when individual 
instruction is given by a competent teacher. 

The parents may later act as monitors and encourage the children to 
go through their exercises daily. As a rule, the little patients delight in 
this, and consider it a pleasure rather than a task. By continuing slow, 
resistant exercises with the deep diaphragmatic breathing, placing the pupil 
before a mirror and teaching him to concentrate his mind upon each move- 
ment, the general tone of the body can be markedly raised. Three time- ;i 
week for fifteen-minute periods usually suffices in the beginning. 

The aim should be not to produce great muscular development, bill 



84: DISEASES OE CHILDREN. 

simply to create a natural demand for proper food, improve the general 
circulation, and bring about better health. 

The indications for these exercises are many, but the best results are 
obtained in children who are shallow mouth-breathers as a result of various 
disorders of the respiratory tract or of nutrition. We have had excellent 
results with this method following adenoid operations, and in rachitic and 
anemic children with perverted appetites. Neurotic children also react 
very favorably. 



CHAPTER X. 

SUGGESTIVE SCHEME FOR DIAGNOSIS. 

To confirm the suggestions for diagnosis in this table the reader can 
refer to the section that treats at length of the disease mentioned. 

Head. 
Size. 

(a) Small — Microcephalus, idiocy. 

(b) Large — Hydrocephalus, rickets, hypertrophia cerebri. 

Shape. 

(a) Square — l Eickets. (Prominent frontal eminences.) 

(b) Asymmetrical — Eickets, cretinism, idiocy, brain tumors, atrophy 

of brain. 

(c) Bulging Forehead — Hydrocephalus. 

(d) Prominent Frontal and Parietal Bones — Syphilis. 

(e) Craniotabes — Syphilis, rickets, chondrodystrophy. 

( / ) Open Sutures — Eickets, hydrocephalus, cretinism, idiocy. 

Position. 

(a) Eetraction — Meningitis, Pott's disease. 

(b) Lateral Deviation — Wry neck, rheumatic torticollis, Pott's dis- 

ease, injury to neck muscles at birth, abscess. (Peritonsilar, 
postpharyngeal or of cervical glands.) Middle ear or mastoid, 
hematoma, sternomastoid, curvature, hysteria. 

Motion. 

(a) Purposeless Movements — Chorea, tics. 

(b) Rythmic — Xodding spasm. 

(c) Flaceidity — Anterior poliomyelitis, coma, late meningitis. 

Fontanel. (Normally open till eighteenth month.) 

(a) Bulging (during cry normal) — Hydrocephalus, meningitis, 

hemorrhages within, brain tumor, thrombosis of sinus. 

(b) Depressed — ■Atrophic constitutional diseases, severe diarrhea, 

first stages of meningitis. 

Tumors. (About the head.) Hematoma, abscess, sarcoma, syphilis, 
encephalocele, hydromeningocele, hernia cerebri. 
85 



86 DISEASES OF CHILDREN. 

Neck. 
Tumors. (About the neck.) 

(a) Parotitis. 

(b) Lymph node hypertrophy. 

(c) Thvroid enlargement. 

(d) Branchial cleft. 

(e) Congenital cysts (blood cysts, angiomata, hygroma). 
(/) Hematoma (especially of the sternomastoid). 

Face. 
Expression. 

(a) Pain (intermittent) — Colic, dentition, dysuria, otitis, bodily 

discomfort. 

(b) Pain (continuous) — Pneumonia, pleurisy, peritonitis. 

(c) Pain (on handling) — Scurvy, fracture, dislocation, rickets, 

spinal paralysis, meningitis, neuritis, rheumatism. 

(d) Anxious — Obstructed breathing or dyspnea from any cause; 

heart disease. 

(e) Cretinoid — (Thick lips, protruding tongue, stolid). 
(/) Sad — (spirituelle). Tuberculosis and chronic diseases. 
(g) Disgust — Dyspepsia, gastritis, abdominal disease. 

(//) Senile — Marasmus, syphilis, internal hydrocephalus. 

(i) Pinched (abdominal) — Peritonitis, cholera infantum, prolonged 

or severe diarrhea, collapse. 
(;) Foolish — Idiocy. 
(A-) Stupid (fish mouth) — Adenoids. 

Mouth. 
Open Mouth. 

Cretinism, rickets, idiocy, coryza, inflammation of the throat. 

Lips. 

Enlarged. — Cretinism, syphilis, adenoids and hypertrophied tonsils, 
infection, neoplasms. 

Fissures and Ulcerations. 

Syphilis, stomatitis, after and during acute infectious diseases, injuries. 

Tongue. 

Enlarged. — Congenital, cretinism, idiocy, inflammatory processes, 
trauma, infection. 



SUGGESTIVE SCHEME FOR DIAGNOSIS. 87 

Fissure* and L' leers. — Syphilis, caries of the teeth, tuberculosis, stom- 
atitis, ulcer of freuum. 

Enlarged Papilla'. — Strawberry tongue of scarlet fever, diabetes, 
lymphatic leukemia, status lymphaticus. 

Geographical. — Intestinal fermentation, tuberculosis. 

Gums. 

Swollen, Bleeding or Spongy. — Gingivitis, acute infectious diseases, 
scurvy, congenital heart disease, leukemia, stomatitis, difficult 
dentition, caries of the teeth, neoplasms. 
Teeth. 

Syphilis (Hutchinson's teeth), cretinism (small pointed), severe 
chronic diseases (notches, ridges, rings). Delayed dentition; rick- 
ets, syphilis (in infancy). Chronic diseases of infancy — Loosening 
and shedding in scurvy, mercury, caries. 

Swallowing. 

(a) Pseudodysphagia. 

Xasal obstruction, sore mouth, parotitis, adenoids, p}'loric stenosis, 
anorexia. 

(b) True Dysphagia. 

Paralysis of soft palate, pharynx or tongue. 

Spasm of muscles in tetanus, chorea, strychnin poisoning, hysteria, 

Thomsen's disease. 
Swellings of tonsils. Peritonsillar abscess. Angina, mediastinal 

glands, thyroid, thymus. 
Mac ro gloss ia . — C retinism . 
Corrosion. Cicatrix. Heat, drugs, syphilis, tuberculosis, trauma, 

ulcer, foreign body. 
Congenital Defects. — Atresia, stenosis, diverticula. 

Abnormalities in Breathing. 
Mouth Breathing in Nasal Obstruction. 

(Noisy breathing, snoring) narrowing or obliteration, congenital ob- 
struction, cretinism, syphilis, deformities, chondrodystrophy, ade- 
noids, polypus, foreign bodies, hematoma, tuberculosis, lupus, 
abscess, rhinitis acute and chronic, injuries. 

Inspiratory Dyspnea. 

(a) Pharyngeal Stenosis. — Enlarged tonsils, chronic neoplasms, retro- 
pharyngeal and peritonsilar abscess. Diphtheria, cold abscess, 



6t5 DISEASES OE CHILDREN. 

tuberculous glands, vertebral caries, microglossia, ranula, neo- 
plasms of tongue and jaw. 

(b) Laryngeal Stenosis. — • Diphtheria, spasmodic laryngitis (croup), 

laryngo-spasm with crowing inspiration, tetany, rickets, hydro- 
cephalus, enlarged bronchial glands, status lymphaticus, mem- 
brane in scarlet and measles, tuberculosis, syphilis, neoplasms, 
urticaria, foreign bodies, drugs, scalding, corrosion, edema 
glottis, edema from renal and cardiac disease, goiter, paralysis. 

(c) Tracheal and Bronchial Stenosis. — Diphtheria, enlarged bron- 

chial glands, thymic disease, goiter. 

Expiratory Dyspnea. 

Emphysema, asthma, spasm of inspiratory muscles, tetanus, tetany, 
epilepsy, hysteria, convulsions (irritation phrenic nerve in pericardial 
effusion). 

Mixed Dyspnea. 

Bronchitis, pneumonia, pulmonary edema, pleurisy, tuberculosis, heart 
disease, the anemias, toxic and acute infectious diseases, diabetic 
coma, uremia, gas poisoning, heat stroke, organic lesions of pons 
and medulla, tumors, abscess and hemorrhages of brain, anterior 
poliomyelitis with cerebral symptoms. 

Chest. 
Shape. 

(a) Barrel Shape. — Emphysema, pertussis, asthma, bronchiectasis, 

chronic bronchitis, pneumothorax. 

(b) Contracted Chest. — Eickets, tuberculosis, stenosis of upper res- 

piratory tract as adenoids and stenosis of larynx. 

(c) Bulging Sternum (pigeon breast). — Eickets, heart disease, per- 

tussis, stenosis alone. 

id) Asymmetrical. — Pleural effusions, pneumothorax, pleural adhe- 
sions, scoliosis. 

(e) Funnel Shape. — Eickets, intraabdominal pressure. 

(/) Harrison's Groove. — Eickets. 

Tumors of Chest Wall. 

(a) Pointing empyema, caries of spine, "bronchial glands, periostitis. 

(b) Breast — (Milk distention, septic mastitis, mumps, true tumors.) 

(c) Bulging precordia, heart disease, pericarditis. 
((1) Hernia of lung. 



SUGGESTIVE SCHEME EOR DIAGNOSIS. 89 

Abdomen. 
General Enlargement or Prominent Abdomen. 

(a) Distention with Gas. — Dyspepsia, gastritis, pyloric stenosis, intes- 

tinal indigestion and dysentery, intestinal obstruction, constipa- 
tion, tuberculosis and septic peritonitis, pneumonia, typhoid, 
congenital dilatation of colon, obstructed hernia, intestinal per- 
foration. 

(b) Fluid. (1) Peritonitis (chronic, serofibrinous, tuberculous, septic 

(from umbilicus), gonorrheal, pneumonic. 

(2) Heart disease (uncompensated heart and chronic adhesive 

pericarditis). 

(3) Kidney diseases. 

(•i) Hepatic diseases (cirrhosis, true tumors, degeneration). 

(5) Portal obstruction (enlarged glands, adhesions). 

(6) Grave anemias. 

(c) Constitutional Diseases. — (Usually from weak spine.) Pickets, 

cretinism, syphilis, marasmus. 

(d) Miscellaneous. — Pott's disease, curvature, congenital dislocation 

of hip. Hysteria. 

(e) Enlarged liver and spleen. 

Enlarged Liver. 

(1) Hyperemia in Sepsis. — Cardiac and pulmonary affections. 

(2) Toxic. — (a) Alcohol, phosphorus, santonin. 

(&) Acute infectious diseases. 

(3) Constitutional Diseases. — Tuberculosis, syphilis, rickets, athrep- 

sia. 

(4) Cirrhosis. — (Acute yellow atrophy.) 

(5) The Anemias. — Leukemia, pseudoleukemia, splenic anemia, 

Banti's disease, primary splenomegaly. 

(6) Abscess, cysts and true tumors. 

Enlarged Spleen. 

(1) Acute infectious diseases. 

(2) Constitutional diseases (as above). 

(3) Hepatic, cardiac and pulmonary (as above). 

(4) The anemias (as above). 

(5) Abscess, cysts and neoplasms. 

Localized Tumors. 

(a) Kidney. — Floating kidney, hydronephrosis, pyelitis, perinephritis, 
neoplasm, cystic kidney, tuberculosis. 



!M.) DISEASES OF CHILDREN. 

(b) Stomach and Intestines. — Pyloric stenosis, intussusception, appen- 

dicitis, impacted feces, worms, neoplasms, congenital dilatation 
of colon. 

(c) Miscellaneous. — Thickened omentum (tuberculous peritonitis), 

mesenteric glands, psoas abscess, encysted peritoneal abscess, 
distended bladder. 

Tumors of Abdominal Wall. 

Abscess, hematoma, hernia (muscular). 

Umbilical Region. 

(1) Hernia (of omentum, intestines, bladder). 

(2) Fungus (granulations). 

(3) Periumbilical abscess. 

Inguinal Region. 
Tumors or Enlargements. 

Hernia, hydrocele of tunica vaginalis and cord. 

Undescended testicle. 

Orchitis, mumps, syphilis, tuberculosis, influenza, trauma. 

Neoplasms. 

Varicocele. 

Delayed Growth. 

(a) Improper feeding and digestion, starvation, pyloric stenosis, 

marasmus. 

(b) Cretinism, rachitis, idiocy, infantilism, osteomalacia, micromelia. 

(c) Tuberculosis. 

(d) Syphilis. 

(e) Valvular heart disease. 
(/) Progressive paralysis. 

Hemorrhages, 
i. General Causes. 

(1) Acute Infectious Diseases. — Pyemia, septicemia. 

(2) Toxic. — Iodids, mercury, ergot, belladonna, phosphorus, anti- 

pyrin, chloral, arsenic, food poisoning, snake bites. 

(3) Constitutional Diseases. — Syphilis, scurvy, Bright's disease, tuber- 

culosis, athrepsia, cachexia. 

(4) Purpura. — Purpura simplex, fulminans, hemorrhagica rheumat- 

ica, Henoch's purpura. 



SUGGESTIVE SCHEME FOR DIAGNOSIS. 91 

(5) Blood Diseases. — Hemophilia, leukemia, pseudoleukemia, splenic 

anemia. Banti's disease, severe secondary and pernicious 
anemia. 

(6) Mechanical. — Injury, pertussis, epilepsy, at birth. 

2. Special Causes. 

(a) Of New-born. — Asphyxia, obstetrical operations, deficient expan- 

sion of lungs, sepsis, syphilis, hemophilia, congenital disease of 
liver and bile ducts. 

(b) From Nose. — 

(1) In new-born as above. 

(2) Affections of mucous membrane. Traumatism, foreign 

body, acute and chronic rhinitis, adenoids, polypus, diph- 
theria, measles, worms. 

(3) Congestion, prolonged cough. Cardiac and pulmonary 

affections. Overheating, nephritis, sinus thrombosis. 

(4) Prodromal, in acute infectious diseases. 

(5) Vicarious menstruation. 

(6) Fractured skull. 

(c) Of Stomach. — Gastric ulcer, chemical erosions, worms, foreign 

body. Occlusion of intestines, swallowed blood, general causes 
as in 1. 

(d) Rectum. — General causes and new-born. Severe enteritis, gas- 

tric and intestinal ulcer, follicular and membranous enteritis, 
worms, intussusception and strangulation, hemorrhoids, polypus, 
anal fissure, condjdoma, prolapse rectum, injury with enemata, 
etc., typhoid, tuberculosis. 

Extremities, 
i. Disturbances of Motion. 

(a) Paralysis or Pseudoparalysis. — Anterior poliomyelitis, scurvy, 
syphilis, rickets, postdiphtheria, cerebral palsy, neuritis, birtli 
palsy, meningitis, fracture, epiphyseal suppuration, osteomye- 
litis, spina bifida, transverse myelitis, progressive muscular 
atrophy. Landry's paralysis. 

(6) Inability to Walk or Walk with Limp.— (Any of the above pa- 
ralyses cited in (a) ). Delayed walking. Tuberculosis of the 
hip, knee, ankle. Pott's disease, osteomalacia, congenital dislo- 
cation of the hip, rickets, coxa vara, rheumatism, mental defi- 



92 DISEASES Or CHILDREN. 

ciency, idiocy, hydrocephalus and microcephalus, cretinism, 
weakness after disease or poor nutrition, progressive muscular 
atrophy, flat-foot, improperly fitted shoes. 
(c) Spastic Extremities {rigidity). — (Normal in early infancy.) 
Gummata, cerebral hemorrhages, sclerosis, tumors, spastic para- 
plegia, acute encephalitis, Little's disease, hydrocephalus, men- 
ingitis, lateral sclerosis, hereditary ataxia, tetany, catalepsy, 
tetanus. 

2. Swellings. 

(a) Joints. — Chronic and acute polyarthritis. (Rheumatic, purulent, 

gonorrheic, following scarlet fever and pneumonia). Tubercu- 
losis of the joints, simple effusion, bursitis. 

(b) Bones. — Eickets (epiphyseal), syphilis, scurvy (subperiosteal). 

Osteomyelitis, neoplasms. 

(c) General Enlargement. — Anasarca, angioneurotic edema, sepsis, 

hydremia, acromegaly, elephantiasis, erysipelas, cretinism. 

3. Hands. 

(a) Dactylitis. — (Simple, tuberculous, syphilitic.) 

(b) Clubbed Fingers. — Heart disease, chronic cough, hepatic cirrho- 

sis. 

(c) Claw Hand. — Ulna paralysis, progressive atrophy, lesions spinal 
• cord, ischemic paralysis. 

(d) Purposeless Involuntary Movements. — Chorea (infectious and 

hereditary, Huntington's). Organic brain lesions (hemiplegia, 
tumors, abscess brain, sclerosis after meningitis). Friedrich's 
ataxia, habit spasm, idiocy, hysteria. 



SECTION IV. 
INFANT FEEDING. 



CHAPTEE XL 
THE INFANT FROM THE NUTRITIONAL STANDPOINT.* 

Introduction. 

The general practitioner is expected to look after the nutritional wants 
of infants. With the average normal baby he can succeed, provided lie is 
grounded in the principles of nutrition. In the succeeding chapters infant 
feeding will be outlined in such a way as to enable the physician to apply 
the principles involved in the management of all infants. It is unwise to 
read or study any one section, without noting its relation to the entire 
subject. 

Infant feeding is perhaps the most difficult of the pediatrician's prob- 
lems, and the general practitioner must realize the need of a careful study 
of this subject. 

The Infant. — The problem of nutrition begins when the fertilized 
ovum starts to divide and form additional cells, and from this time on until 
death there is an unceasing demand for food. During a life history the 
food is supplied in many different forms, and as the organs of nutrition 
change in the earlier stages of development, the physical properties of the 
food change also. In the earliest stages the food is supplied from the yolk 
of the ovum ; as development progresses, the villi of the chorion appear and 
act as organs of nutrition; these gradually merge into the placenta, which 
derives food from the maternal blood ; at birth the breasts supply food in the 
form of colostrum for a few days, which is gradually displaced by milk. 
When the milk supply naturally fails, toward the end of the first year, the 
child is capable of digesting some forms of semisolid food such as its 
parents eat, and continues its development on this food. 

Essential Unity of Foods. — When all forms of food, including 
mother's milk, are subjected to chemical analysis they are found to be com- 

* For greater details in reference to the biolosry of this subject, see " Theory 
and Practice of Infant Feeding," by Dr. H. D. Chapin. Third edition. William 
Wood & Co. 

93 



94 



DISEASES OF CHILDREN. 



posed of ingredients which fall into five groups : Proteins, oftentimes 
termed proteids, which form the tissues; mineral matter which is necessary 
for bone formation, and also in lesser quantities to replace metabolic waste ; 
fats and carbolrydrates which supply the energy; and water. The great 
difference in foods at different ages is not one of composition, but of form. 

Foods of the First Nutritive Period. — The mother supplies food to 
her offspring in six different forms : First, the yolk of the ovum ; next the 
fluid in which the ovum is bathed; then that which is supplied in a form 
suited for assimilation by the chorion; and then by blood which circulates 
through the placenta. When birth occurs, the food is supplied through the 
breasts in two forms, at first colostrum and finally as milk. 

Each of these forms of food is specially adapted to the infant at the 
time it is furnished, and as soon as the infant outgrows one form of food 
another is supplied. 





Fig. 28. — Normal human milk. 
(Jeicett.) 



Fig. 29. — Colostrum corpuscles. 
(Jeicett.) 



Breast Secretions: Specialized Foods. — It is plain that before 
birth the form of the food supplied by the mother and the method of fur- 
nishing it change to suit the state of development of the fetus; and as at 
birth the digestive organs of the infant are not fully developed, it may be 
concluded that in some way the breast secretions are peculiarly adapted for 
that part of the first nutritive period in which the digestive tract is 
rleveloping. 

Composition and Properties of Breast Secretions. — The first secre- 
tion of the breasts or mammary glands after the infant or young animal is 
born is called colostrum. Chemical analysis shows it to be composed, like 
all foods, of proteins, mineral matter, fats, carbohydrates, and water. 



THE INFANT FROM THE NUTRITION STANDPOINT. 



95 



Upon boiling, colostrum coagulates, owing to a large portion of the 
protein being in the form of albumin. It is also distinguished by the pres- 
ence of colostrum corpuscles (Fig. 29). In the course of a few days after 
birth the character of the breast secretion undergoes a complete and radical 
change. The later secretion is milk, which is also composed of protein, 
mineral matter, fats, carbohydrates, and w T ater, but it will not coagulate 
when boiled, showing there has been a change in the character of the pro- 
tein, and the colostrum corpuscles are absent. From these facts it is evi- 
dent that chemical analysis throws little light on the properties of either 
colostrum or milk, except to show that they are composed of the basic food 
elements. 

As the characteristic feature of nutrition during the first nutritive 



Teeth and 
salivary glands. 



Stomach. 



Intestines 




Fig. 30. — Development of human digestive tract. 
(Allen Thompson and Wiedersheim.) 



period is the adaptation of the form of the food by the mother to the organs 
of nutrition of the fetus, which are constantly undergoing change, it is 
evident that the way to acquire a knowledge of the properties of the breast 
secretions is to study them in relation to the infant's digestive organs. 

Development of the Digestive Tract. — At birth the digestive organs 
are quite different both anatomically and physiologically from those of the 
adult. Teeth are absent, which in the adult reduce the food to a state of 
fine subdivision, to fit it for the stomach, and the gastric secretions particu- 
larly are not like those of the adult, and in some animals the stomach is noj 
fully formed. During the colostrum period there is little gastric secretion, 
but when the mother secretes milk, the rennet ferment or rennin, which is 
closely allied to pepsin, is secreted in the stomach. Rennin prepares the 



96 DISEASES OF CHILDREN. 

milk for stomach digestion by the infant in much the same manner as teeth 
prepare the food for digestion later in life. That is, rennin acts upon a 
portion of the milk and changes it from a fluid into a semisolid which has on 
a small scale much of the physical property and texture of the chewed food 
of the adult. Until pepsin and acid are secreted, true gastric digestion 
does not take place and the solid remains very soft; but when acid appears 
it in some way combines with the solidified milk, rendering it more solid 
and fitting it for digestion by pepsin. Thus it is that the first solid food for 
the undeveloped digestive organs is produced from the specialized food 
supplied by the mother, and its digestive properties are altered or adapted 
to the stomach by the gastric secretions. 

Comparative Mammary Secretions. — As far as known, all mammals 
secrete colostrum for a few days after birth takes place, and this secretion 
is followed gradually by milk, but the milks of different species show wide 
differences in their properties. When they are subjected to chemical analy- 
sis, it is found they all agree in being composed of proteins, mineral matter, 
fats, carbohydrates and water, although the proportions of these ingredients 
are not the same in all kinds of milk or in the milk of different individuals 
of the same species. It might appear from this that the differences between 
milks of different species were clue merely to the varying proportions of the 
food elements present, but when it was known how little idea of the prop- 
erties of a food is shown by the report of its chemical analysis, the limited 
value of food analyses in infant feeding was appreciated. 

However, it must not be supposed that a chemical analysis of food or 
milk has no value, but its true value should be recognized and not over- 
estimated. 

The proper way to compare milks for infant feeding is to see how they 
react to rennin, pepsin, and acid, and how they compare in composition. 
Milks of different species show great differences, although they may have 
identically the same composition; that is, be composed of the same quan- 
tities of proteins, mineral matter, fats, carbohydrates, and water. Human 
milk is changed into a semisolid, finely divided mass by rennin, pepsin and 
'<u-\<] ; cow's, goat's, and sheep's milk into a solid mass which is of the same 
volume as the milk; mare's and asses' milk into a fluid jelly. This results 
from the action of rennin on a portion of the protein generically termed 
casein, or by some caseinogen. When the digestive organs of various ani- 
mals arc compared, they are found to differ in form or in their physiological 
action. Mother's milk is digested in much the same manner as the food 
will be after weaning has taken place. In other words, nature demands 
that the food should be adapted to the species. 



THE INFANT FROM THE NUTRITION STANDPOINT. 97 

Animals that grow rapidly need larger quantities of proteins than 
those which grow more slowly and the mothers of animals whose growth 
is rapid secrete milk much richer in proteins than mothers of animals 
whose growth is slower. 

In practical feeding it is found that milks of different species are not 
interchangeable from a digestive standpoint, although they are all highly 
nutritive, but the reason was not discovered until infant feeding was studied 
from the standpoint of milk as a specially adapted food, and the subject 
was considered from a biological standpoint. 

Chemical and Biological Standards in Infant Feeding. — There 
have been used from time to time various methods of making cow's milk 
agree with infants, such as adding lime-water, bicarbonate of sodium, 
citrate of sodium, and ]3eptonizing materials, which have produced chemical 
changes, each of which has been claimed to make cow's milk like human 
milk. These methods have been confusing and contradictory and have 
made the whole subject chaotic. The aim has been to make human milk 
by chemical means and the standards used in feeding until recently have 
been purely chemical. But as the effects of the different methods in prac- 
tice have been studied it has been found that they do not make human 
milk, but either change the character of the proteins of cow's milk, or alter 
the action of the digestive secretions of the infant on the milk, so in reality 
while the theory has been that chemical changes were utilized to make 
human milk of cow's milk, practice has been along the line of adapting 
food to the infant. Theory and practice have been diametrically opposed 
and naturally great confusion was the result. 

Since the recognition of the fact that it is impossible to make human 
milk from other substances as yet, and that the practice is to adapt food 
to the infant, the biological standard of feeding has assumed greater 
importance and makes theor} T and practice coincide. 

This standard or principle may be stated as follows : 

.1/ all stages of life the foorl must be composed of proteins, mineral 
matter, fats, carbohydrates, and water. 

Those elements exist in a great variety of forms which are equally 
nutritious, but ore not er/vallji adapted for tire digestive organs at all ages, 
or for all species of animals, as their digestive organs arc not alike. 

The peculiarities of the digestive organs must be first considered, and 
after this has boon done food must be selected that is adapted for the 
particular digestive tract. 

After such a foorl has been found its composition must be looked after 
SO that enough of the elements necessarji to produce proper growth and 
development may be assured. 



98 DISEASES OE CHILDREN. 

In the treatment of practical feeding this plan will be followed, and 
the prominent position heretofore given to the supposed chemical differ- 
ences between human milk and other foods will not be found in this work. 
The chemical side of feeding will be subordinated to the physiological 
aspect, for in practice all that the chemical composition of a food shows is 
its possible nutritive value, its actual value for each infant being a subject 
for determination by experiment with the infant. 

Recapitulation. — The main points to be kept in mind in infant- 
feeding are : 

The mother's breast secretions are specialized forms of food, adapted 
to the developing digestive organs. 

Milks of lower animals and table food are as nutritious as mother's 
milk, but are not adapted to the undeveloped condition of the Infant's 
digestive tract. 

The chemical composition of a food shows nothing concerning its 
suitability for any animal and is not of first importance. 

The value of foods for individuals cannot be judged by comparing their 
chemical composition alone. 

Foods may be " chemically right but practically wrong." 

The food elements required by all infants are the same, but the form 
in which they are to be presented must be determined for each infant. 



CHAPTER XII 
BREAST-FEEDING. 

Importance of Breast-feeding. — The breast secretions are furnished 
during the time the infant's digestive apparatus is developing, and serve 
a purpose in addition to supplying nourishment. The secretions of the 
breasts adapt themselves to the increasing strength of the digestive organs, 
and, instead of these organs finding their work easier as they become 
stronger, they find the digestive work increases as their digestive capacity 
becomes greater. This is brought about by an alteration in the physical 
properties of the mother's milk in the stomach by the infant's gastric 
secretions before true digestion commences. The rennin, pepsin and acid 
of the stomach, as they successively appear, produce profound changes in 
the physical condition of the milk. When rennin acts alone, as it does in 
very early infancy, the milk becomes a fluid jelly ; but later on when pepsin 
and acid appear the milk is changed into a mass having much of the con- 
sistency of well-chewed food, and which should be looked upon as its proto- 
type. It is thus that the digestive organs are prepared to digest semisolid 
food about the twelfth month, when weaning naturally takes place. In 
addition to this interesting and important property of the mother's milk, 
it generally contains the food elements in the proportions and forms best 
suited for proper nutrition of the infant. 

It is not a difficult matter to bring together the food elements in the 
same quantities as are found in any specimen of breast milk, or colostrum, 
but even when derived from milk of lower animals the food does not have 
the delicate properties of the breast secretions, and it is often contaminated 
or has undergone bacterial changes. 

While many infants are successfully fed on substitutes for breast 
secretions, such feeding should not be attempted until every effort to secure 
breast-feeding has failed. 

The death rate is much higher among artificially fed infants than 
among those breast-fed, and in hot weather when bacterial changes in the 
food are greatest the loss of artificially fed infants is several times greater 
than during the colder seasons, while the increase in death rate among 
breast-fed infants is Blight. 

Everv consideration shows the advantage of employing the maternal 
method of nutrition while the infant's digestive organs are developing, 
and breast-feeding should always be advocated unless contraindicated (see 
p. 105). 99 



10U DISEASES OF CHILDREN. 

Preparation for Maternal Feeding.— For some months before de- 
livery, the nipples should be treated so as to prepare them and thus prevent 
tenderness or fissure when the infant nurses. This is done by gently rubbing 
and applying such a lotion as the tincture of benzoin. Depressed or mis- 
shaped nipples may thus be made usable, and the comfort of the mother will 
also be conserved. 

Management of Breast- Feeding. — When the mother is enough 
rested after delivery the infant should be offered each nipple. If it does not 
seem satisfied and becomes fretful or restless, a teaspoonful or two of boiled 
water may be given. This will quiet the infant and helps to flush out the 
digestive tract and kidneys. 

For the first day of two the infant may be offered the breast every 
three hours during the day and twice during the night, at four- to six-hour 
intervals. After this it should be nursed every two hours during the day 
and once or twice at night. 

When the supply of milk is sufficient the infant will suck for fifteen 
to twenty minutes and then drop off to sleep. If after having the nipple 
twenty to thirty minutes the infant seems restlses and unsatisfied it may 
be suspected that the milk supply is insufficient. A weighing before and 
after nursing will help to determine whether the amount has been sufficient. 
After the first few weeks such a test should show an increase in weight of 
between two and three ounces. 

If under such management the infant has soft yellow stools with no 
pronounced signs of indigestion and gains steadily in weight, it may be 
considered as doing well. 

Regularity of Feeding Important. — One of the most fruitful causes 
of indigestion in breast fed infants is feeding at irregular, and especially 
at short intervals. Sometimes a fresh feeding is taken into the stomach 
before the previous meal has been digested, which is bad enough; but in 
addition to this, the irregularity in nursing has a profound effect on the 
com position of the mother's milk. 

If the intervals between nursings are long there will be a large quantity 
of lather poor milk; but when the milk is drawn at short intervals it has 
the effect of reducing the quantity and greatly increasing the percentage 
of fat, the other ingredients not being affected to any great extent. An 
excess of fat in the food is apt to produce vomiting, and an abnormal gastric 
secretion may follow, causing the milk to curd or solidify abnormally ; hence 
it is not difficult to see why frequent nursing causes digestive disturbance. 
When milk is drawn at regular intervals it has practically the some compo- 
sition, unless the mother has been subjected to influences that derange her 



BREAST-FEEDIXG. 101 

nervous system. These may profoundly alter the character and composition 
of her milk and produce great disturbances in the infant. It is, therefore, 
of the greatest importance to have the mother regular in her own habits 
and free from excitement, and that the infant be fed at regular hours. It 
will be helpful if the mother is given ■ directions for feeding by the clock, 
as at 5, 7, \K 11 A. M.; 1, 3, 5, 7, 9 P. M., and once during the night in 
occasional cases. 

Milk Agrees, Flow Scanty.— When the mother's milk agrees with 
the infant, but is not sufficient in quantity to cause it to gain in weight 
steadily, attempts should be made to increase the flow, and when these are 
not successful, mixed feeding, that is, part breast and part artificial feeding, 
must be employed. 

If the mother is to secrete sufficient milk she must digest and assimilate 
a liberal supply of food herself, for unless she does this the milk will be 
produced from her own tissues and she will lose in weight. The diet of 
the mother should consist of simple, easily digested food in liberal quantity, 
milk, eggs, meats, and thoroughly cooked cereals being the mainstay. Tea 
and coffee should be withheld or used sparingly, cocoa or chocolate being 
given in their place. 

Southworth, who has devoted much attention to this matter, recom- 
mends the use of cornmeal gruels to be taken between meals as a means of 
increasing and conserving a scanty flow of breast milk. When cornmeal 
gruel is not relished, oatmeal gruel may be substituted. The gruels are 
made as follows : 

Two to four heaping tablespoonfuls of yellow cornmeal or rolled oats are 
placed in one quart of cold water in a double boiler and tbe water in the boiler 
is kept boiling for two or three hours. The gruel is then strained through a 
coarse wire strainer and enough boiling water is added to make one quart of 
gruel. The gruel should be well salted. It is often advantageous to add an 
equal quantity of milk. 

A pint of such gruel is to be taken about ten o'clock in the morning 
and again at about three in the afternoon. The gruel, when dextrinized, 
supplies energy food in a form quickly assimilable, and the coarse particles 
of the gruel undoubtedly promote normal action of the bowels and thus 
promote the general well-being of the mother and incidentally that of the 
infant. When there is anemia iron should he administered. 

Elimination of Drugs and Excretory Products in Milk. — It is a 
well-known fact that some substances pass into the milk from the mother's 
system which may unfavorably affect the infant. Constipation of the 
mother will affect the infant unfavorably, and under certain conditions 
urea in appreciable quantities finds its way into the milk. When the mother 



102 DISEASES OF CHILDREN. 

is constipated and the use of cornnieal gruel does not overcome the condi- 
tion, cascara should be given. 

Great care must be exercised in giving drugs to nursing women, as 
they may be excreted in their milk. Morphin, mercury, quinin, iodid of 
potassium and similar preparations should be given cautiously and their 
effects watched. 

Milk Plentiful, but Disagrees with Infant. — As a general rule, the 
milk of the mother will agree with her infant. However, there are some 
women whose milk may at times be excessively rich in all of its elements or 
may fluctuate widely in the amount of fat present or have properties that 
make it unacceptable to the infant. 

If the milk agrees with the infant for a time and then suddenly dis- 
agrees the probabilities are that the mother has been subjected to excitement 
of some kind ; it may be worry, fright, anger, grief, or loss of sleep that has 
made her irritable. Such influences will produce sudden changes in the 
character of milk and alter its digestive properties. It is well known that 
the milk of a cow that has been overheated, driven rapidly, or made irritable 
by flies or dogs, will not react normally to rennin and acid. The changes 
brought about by these nervous influences are more than variation in 
percentage composition, and cannot be detected by chemical analysis. The 
remedy in this class of cases is to remove all causes of anxiety and nervous 
disturbance, and have the mother sleep in another room so that she shall 
not be disturbed by the infant's crying. Pleasant surroundings, and mod- 
erate daily exercise in the fresh air are also indicated. 

Sometimes the milk of one breast is perfectly satisfactory while that of 
the other causes disturbance. In such cases the remedy is to secure all of the 
feedings from the good breast if possible until the other one secretes normal 
milk. 

When the milk disagrees from the start and the mother seems healthy 
it is possible that the trouble is caused by the milk being too rich, the result 
of overeating on the part of the mother. At any rate it is helpful in all of 
these eases where the milk disagrees to make an examination of it, as will 
be explained below. 

If it is found that the amount of fat and total solids in the milk is 
too high the diet of the mother should be restricted, and exercise to the point 
of fatigue, to divert the food supply from the breasts, may be advised. It 
may also be necessary to give saline cathartics. If there is an over-abundant 
supply of rich milk, the infant should be allowed to take only the first milk 
from each breast and thus avoid the extra fat " strippings " or the last milk 
secreted which contains a much higher percentage of fat than the first part 



BREAST-FEEDIXG. 103 

of the secretion. If the infant has curdy stools and colic, a tablespoonful of 
barley water, limewater. or water containing one grain sodium citrate may 
be given just before each nursing. 

If the methods of management suggested above do not overcome the 
difficulty, so that the infant gains from four to six ounces a week, with 
good digestion and normal stools, it will be necessary to resort to mixed 
feeding. Give a bottle every other feeding, using a formula suitable for a 
younger infant at the beginning, as described on page 134. 

Examination of Breast Milk. — There are two ways of examining 
breast milk : ( 1 ) by having an analysis made showing its percentage com- 
position expressed in proteins, mineral matter, fats, carbohydrates, and 
water: (2) by roughly determining these ingredients by means of the 
amount of cream that will rise on a given quantity of milk and the specific 
gravity of the milk. 

The chemical analysis of milk is expensive, and its value is apt to be 
overestimated. It takes several days to get a report from the laboratory 
where it is made, and laboratories for this purpose are not always available. 
The second method of determining facts and specific gravity takes twenty- 
four hours, but can be utilized anywhere. A specimen of the milk is drawn 
from the breast, care being taken to get all there is, because the first portion 
contains little fat, while the last portion or " strippings " is very rich in fat. 
The milk is mixed and its specific gravity is taken with an ordinary urin- 
ometer. Ten cubic centimeters of the milk are then placed in a graduated 
ten c.c. tube or graduate and allowed to stand twenty-four hours for the 
cream to rise. Poor milk will have a small layer of cream and rich milk 
a much thicker cream layer. The amount of fat in the milk is thus esti- 
mated. The specific gravity of normal human milk is about 1.031. If the 
milk shows a layer of cream not over one c.c, and has this specific gravity, 
it may be looked upon as normal milk as far as percentage composition is 
concerned. If the specific gravity should be as low as 1.028, with more 
cream, it would indicate that the milk was rich in fat, as the fat being 
lighter than the milk serum reduces the specific gravity of the milk. 

This method is widely used in the dairy industry for calculating the 
composition of cow's milk, but the fat is accurately determined by the 
Babcock test, which may also be used with human milk. About half an 
ounce of milk is required for this test, but if this quantity cannot be 
obtained, what is available may be diluted with water two or three times 
after the specific gravity has been obtained and the result multiplied by the 
number of times the milk was diluted. 

If the specific gravity is above 1.0.°,0 and there is little cream, or fat 



104 



DISEASES OE CHILDREN. 



shown by the Babcock test, the milk is poor in fat and normal in other solids, 
or all of the milk was not drawn from the breast and that portion containing 
the fat was left behind. A second specimen should be drawn and greater 
care taken to get all there is. The milk should be drawn at the regular 
nursing interval or milk extra rich in fat will be obtained, for, as stated 
before, milk drawn at short intervals is abnormallv rich in fat. 





Fig. 31.— Breast 
pump. 



Fig. 32. — Hoover 
breast pump. 



An estimation of the total solids and solids not fat may be obtained from these 
figures, j. e>j the last two figures of the specific gravity divided by four and adding one- 
fifth of the percentage of fat which gives the solids not fat — then if the fat is added to 
these solids we obtain the total solids. 

For example: (Sp. gr. 1028 — butter fat 5%) 28 s- by 4 = 7 + § (of 5%) = 7.1 solids 
not fat + 5 or 12.1 = total solids. 



At one time great importance was laid upon the reaction of breast milk. It 
was supposed always to be alkaline or amphoteric in reaction. At present com- 
paratively little importance is attached to the reaction of breast milk, for the 
same specimen of milk may be found to be acid, amphoteric, and alkaline, all 
depending upon how the reaction is determined. Litmus-paper was the substance 
used to determine the reaction of milk, a strip being dipped into the milk and its 
reaction judged by the change of color of the litmus-paper. Litmus and litmus- 
paper vary a great deal in sensitiveness, and all kinds of reactions can be obtained 
witb milk by using different lots of litmus-paper. Phenolphthalein in 1 per cent. 
alcoholic solution is now used as the indicator in testing the reaction of both 
human and cow's milk, as it is many times more sensitive than litmus. Lime- 
water is usually employed in neutralizing acidity in milk, and it takes about 10 
per cent, to 20 per cent, to make human milk alkaline to phenolphthalein. With 
a better understanding of the chemistry of milk and the process of its digestion, 
it is seen that undue importance was placed upon its reaction and composition, 
and simpler and better methods of clinically testing the suitability of breast milk 
are coming more into use. 



BREAST-FEEDING. 105 

Nursing not Possible. — When the nipples are fissured it is impossible 

for the infant to nurse, and the milk should be drawn with a breast pump, 
two forms of which are shown in Figs. 31, 32. The Hoover breast pump 
(Fig. 32) will be found convenient and easy to use. Heating an empty 
bottle and placing the neck over the nipple will sometimes prove satisfactory 
in collecting milk. The milk may be fed through a medicine dropper or 
from a small nursing bottle. Pumps and bottle should be kept scrupulously 
clean. 

Where there is but a slight fissure or abrasion which causes pain 
to the mother, a nipple shield (Fig. 33) may be used. It is best 
to (ill it with warm water so that the infant will not have to exhaust 
the air it contains before obtaining any fluid. It 
is also well to massage the breasts to aid in secur- 
ing the milk. The nipples shculd be carefully 
washed with a solution of boric acid and dried 
after use. 

Contraindications for Nursing. — When the 
mother is anemic and is losing weight and shows 
signs of exhaustion, even after tonic treatment has 
been employed; or when she is nervous and excitable 
to such an extent that her milk continually disagrees 
FlG * '5i'm ? ipple with the infant, supplemental or complemental feed- 

ing should be first tried. If when menstruation is 
resumed the milk disagrees, artificial feeding may be employed temporarily, 
and after the period has passed breast-feeding may be commenced. In the 
meantime the breast should be emptied with a breast pump at regular 
intervals to keep up the secretion. If the milk disagrees but slightly it may 
not be necessary to feed artificially. 

If pregnancy occurs it may be necessary to employ substitute feedings, 
but in the middle of a hot summer it will be better to continue the breast- 
feeding, if it is not too much of a strain on the mother, than to risk the 
dangers of commencing artificial feeding in hot weather. Mothers affected 
with tuberculosis should under no circumstances be permitted to nurse 
their infants. Diseases such as typhoid, pneumonia, and septicemia in 
which there is much pyrexia and prostration also are contraindication- to 
nursing. 

A wet-nurse with syphilis must not be allowed to nurse any other 
"infant than her own. 

An otherwise healthy mother may without fear nurse her syphilitic 
infant, for we believe to-day that she is infected, having borne a syphilitic 
child. 




106 . DISEASES OF CHILDREN. 

Weaning and Mixed Feeding. — When the physician has satisfied him- 
self beyond doubt that the mother's milk has failed in quantity or quality, 
it becomes necessary to commence substitute feeding to make up the de- 
ficiency. It is a good plan to have one bottle a day given to a nursing infant 
about the third month so it shall be trained to its use and the mother 
trained in the preparation of food. This will be much appreciated in cases 




Fig. 34.— Preferable type of breasts for wet-nursing. 

where sudden weaning becomes necessary. The substitute feeding may 
alternate with breast-feedings, and as the breast secretion fails the number 
of bottles given may be increased one at a time. In this way the transition 
i- gradual and digestive disturbances are avoided. During the first few 
weeks of life, when the nursing mother has little milk, a small amount may 
be given from the bottle immediately after nursing if the infant gets too 
little from the breast. 



BREAST-FEEDIXG. 107 

Whenever sudden removal from the breast becomes necessary a wet- 
nurse should be employed if possible, as no substitute feeding can compare 
with good wet-nursing. 

Selection of a Wet-nurse. — In selecting a wet-nurse, we must con- 
sider her age, her general health and development, her probable nervous 
status, and the age and health of her infant. The preferable age for the 
nurse is between twenty and thirty years, and multiparas are apt to do better 
than primipara? on account of having had charge of the suckling and gen- 
eral care of infants. A careful physical examination of the applicant should 
be made by the physician. Constitutional taints, especially syphilis and 
tuberculosis, must be excluded by a painstaking history and thorough ex- 
amination of the mouth, lymph-glands, skin, and other parts likely to show 
evidences of infection. If any vaginal discharge is present, it must be 
examined for gonococci. The best breasts for satisfactory suckling are not 
the large, firm ones, but rather the more flabby and pendulous kind, as 
shown in Fig. 34. The nipple must be of good form and size and suffi- 
ciently protuberent for easy grasping by the infant, and free from fissures 
and abrasions. A woman of quiet, phlegmatic temperament, in good health, 
is to be preferred, as nervous instability has a quick effect on the composi- 
tion of the milk. A woman whose infant is under six months can usually 
suckle a new-born baby, but a less disparity between the ages of the infants 
is desirable if it can be attained. A careful examination of the nurse's 
infant must be made to exclude any constitutional disease, and a blood ex- 
amination for the AVassermann reaction should be made. The examination 
will also show how well the infant has thriven npon its mother's milk. The 
diet of the wet-nurse, when selected, should be as nearly as possible that to 
which she has been accustomed, avoiding a too great variety and quantity of 
food. If she is furnished a diet richer and more abundant than she is 
accustomed to, she will in all probability overeat and bring on either de- 
fective digestion or excretion, which will promptly disorder the digestion 
of the infant. Regular outdoor exercise must also be insisted upon. Several 
nurses will sometimes have to be tried before a breast that agrees with the 
babv is found. 



CHAPTER XIII. 

THE PRINCIPLES AND THE MATERIALS USED IN 
SUBSTITUTE FEEDING. 

Difficulties Encountered.- — In taking Tip the study of the artificial 
feeding of infants, one of the first impressions received is that the whole 
subject is undetermined. Methods that give good results in some 
instances totally fail in other cases. One infant will thrive on a 
quantity of food that is insufficient for another of the same age; 
another may gain in weight rapidly and still not be rugged and well- 
developed. The parents may be poor, ignorant or careless, and great diffi- 
culty may be experienced in getting a supply of suitable food, or in having 
the food prepared and administered properly. Learning the formulas of 
a few food mixtures will never make a good or successful infant feeder. 
What is required is a clear conception of what are the essential principles 
involved in artificial infant-feeding in health and disease, and a working 
knowledge of how to prepare food so that these principles may be complied 
with under different conditions. 

Principles that Apply to All Infants. — All infants require a certain 
quantity of proteins and mineral matter to replace normal metabolic waste, 
and enough fats and carbohydrates to supply the energy needed to carry on 
the processes of life. A food that supplies exactly these quantities of the 
food elements is called a maintenance ration, and on such a food the infant 
would neither gain nor lose. Oftentimes in cases of illness it becomes 
necessary to put infants on such food, and the parents may feel the infants 
are being starved, but they are not on a starvation diet by any means; 
growth is suspended temporarily, but the infant is holding its own. 

After the portion of the food needed for maintenance has been appro- 
priated, what remains, if any, may be utilized for growth or for causing gain 
in weight which does not necessarily mean that the infant is really growing. 
Growth consists in an increase in number of the cells of the various tissues. 
and as these are composed principally of proteins and water the food must 
contain a greater quantity of proteins than is required to replace waste, if 
growth is to be made possible, for cells cannot be formed from fats and car- 
bohydrates. A rapid gain in weight may result if the food given contains 
only a little more protein than is necessary to replace waste, but considerable 
fat and carbohydrates, as the excess of these ingredients is converted into 
bodv fat which causes increase in weight. To those not familiar with the 

108 



PRINCIPLES AND MATERIALS USED IN SUBSTITUTE FEEDING. 109 

principles of infant-feeding this gain in weight is strong evidence that the 
food is suitable for the infant, but not so much importance is attached to 
mere gain in weight as formerly. If the food is known to contain a liberal 
supply of proteins, and gain in weight follows its use, it is considered that 
the gain in weight is caused by true growth, as it is characteristic of young 
animals of all kinds to greedily assimilate and convert into tissues the pro- 
teins that the food contains in excess of that needed to replace waste, 
within reasonable limits. Proper growth hinges on the proteins of the food. 

If the food contains a relatively large proportion of proteins with a 
too small proportion of fats and carbohydrates the proteins will be used to 
supply energy which could just as well be furnished by fats and carbohy- 
drates, and growth will not take place. If the quantity of fats and carbo- 
hydrates is increased and the amount of proteins decreased somewhat the 
infant will be able to make a satisfactory growth, therefore it is important 
to have the food elements present in the food in certain relative proportions 
if best results are to be obtained. 

The essentials of artificial infant feeding are : a liberal supply of pro- 
teins and mineral matter for the construction of additional tissue, which 
means growth ; a sufficient supply of fats and carbohydrates to furnish 
energy, and all in forms that can be not only digested by the infant, but 
which permit the development of vigorous digestive organs. A strong 
digestive apparatus is of great importance in after-life, and by proper 
selection of food in infancy the foundation for good digestion later on can 
be laid. 

Cow's Milk; General Composition. — Chemical analysis shows the 
milk of all cows to be composed of proteins, mineral matter, fats, carbohy- 
drates, and water, but the proportions of these ingredients are not the same 
in all specimens of milk from the same cow or from the cows of different 
breeds. The composition of milk depends largely on the breed of cow, the 
individual peculiarities of each cow, and the time and manner of milking. 

One Cow's Milk. — It was formerly believed that the milk of one cow 
was preferable to the mixed milk of a herd of cows for use in infant- 
feeding, but as improved and more sanitary methods of handling herd milk 
have done away with much of the contamination which brought such milk 
into disrepute, it is now much better to use the mixed milk of a large 
number of cows, especially as it is more uniform in composition, less liable 
to sudden fluctuations, changes of properties, and disease carrying possi- 
bilities. 

The range of composition of the milk of single cows has been found to 
be from 2.25 per cent, to 9 per cent, of fat, and 2.19 per cent, to 8.56 per 



110 DISEASES OE CHILDREN. 

cent, proteins (Van Slyke), while in mixed herd milk there is seldom 
much of a range of variation, the fats running almost never below 3 per 
cent, and very seldom over 5 per cent., except in the milk of high-bred 
Guernsey and Jersey cows; while the proteins will almost always run 
between 3 per cent, and 3.5 per cent. 

Influence of Breed on Composition of Milk. — The milk of different 
breeds of cows shows marked differences of composition and no amount of 
effort will make the cows of one breed give milk of the same character as 
the cows of another breed. Holstein cows will give milk containing about 
3 per cent, fat, 2.80 per cent, proteins, and 4 per cent, carbohydrates, while 
Jersey cows will give milk containing as high as 5.5 per cent, fat, 3.60 per 
cent, proteins, and 5 per cent, carbohydrates. 

Bacteriology of Milk. — Milk as secreted by a healthy udder is prac- 
tically sterile, but just inside the teat is a " milk cistern " to which bacteria 
from outside find access. For this reason the first three or four jets from 
each teat should be discarded and then the milk will be quite free from 
bacteria if received under proper conditions into sterile pails. Milk from 
unsanitary dairies contains hundreds of millions of bacteria to the cubic 
centimeter, but fortunately most of these bacteria are saprophytes, and the 
harm they do is chiefly in souring the milk by converting its sugar into 
lactic acid or decomposing the proteins. In hot weather the heat favors 
development of new bacteria and the milk does not keep. This led to a 
demand for sterilization or pasteurization, but it has since been found that 
it is much better to produce milk under sanitary conditions and thus keep 
down the number of bacteria than to kill them by heat after they have been 
allowed to get into the milk. 

In the modern dairy the milkers wash their hands and wear clean 
clothes. They sterilize the milk pails and cans. If there is an infectious 
disease, such as scarlet fever or typhoid fever in the family of any of those 
who handle the milk they are not allowed to take part in its production. 

The principles involved in the production of wholesome milk are now 
well understood, and are being applied more and more even in remote 
parts of the country, and good milk suitable for feeding infants can be 
produced anywhere by the exercise of care and cleanliness. 

Production of Sanitary Milk. — All that is needed to produce milk 
suitable for feeding infants are cows that are free from tuberculosis or other 
disease, a stable that can be kept clean — an ordinary barn will do — and 
careful attention to keeping the cows and utensils clean. The cows are to 
be cleaned daily and kept as sleek and clean as horses. The hair on the 
udder is to be kept cut short and the udder and belly are to be wiped off 



PRINCIPLES AND MATERIALS USED IX SUBSTITUTE FEEDING. Ill 

with a clamp cloth just before milking. No loose hay or manure is to be 
left in the stable when milking is going on, as dust from them carries 
bacteria with it into the milk. All utensils are to be washed with boiling 
water, and steamed if possible. The milker should wear clean clothes, and 
his hands should be washed with soap and water just before milking. The 
first few streams of milk from each teat should be thrown away, not into 
the milk pail, but into the manure gutter, and the milking should then 
proceed into a small-mouth pail. The milk should then be strained through 
a sterile cloth and cooled and iced and kept iced until ready for consumption. 

The bacterial condition of milk is of as much importance as its chemical 
composition and should never be left out of consideration. It is well also 
to remember that methods of milk production in America and Europe are 
totally different, and that European literature on this subject does not 
always apply to American conditions. 

Market Milk. — From a commercial standpoint milk may be divided 
into three grades : ( 1) " Grocery milk," such as is sold at very low prices 
in city grocery stores, especially in the tenement districts, and dipped out 
of cans into the family pitcher; (2) bottled milk, such as is delivered to 
families in glass bottles in the more well-to-do sections; (3) sanitary, 
inspected, or certified milk, which is also sold in bottles. 

Grocery milk is produced at as low a cost as possible and contains 
enormous numbers of bacteria, as no more care is taken in its production 
than the health authorities insist upon. It is a poor food for infants, 
especially in hot weather, when it may be positively dangerous. 

Bottled milk is generally produced under much better conditions than 
grocery milk and sells for about double the price of the grocery milk. It 
forms a satisfactory milk for infant feeding in a large number of instances. 

Sanitary, inspected, or certified milk is produced under the super- 
vision of a commission of physicians, usually appointed by a local medical 
society. Such commissions furnish standards of cleanliness and bacterial 
count which are to be complied with. Then if the milk when taken at 
random from the milkman's delivery wagon comes up to the standard, he 
is furnished with a label certifying that the milk is of the required quality, 
or "certified milk," as it is often called. The standards fixed by "milk 
commissions" in different cities are not all alike. In Philadelphia, for 
instance, the number of bacteria per cubic centimeter must not exceed ten 
thousand, while in New York the maximum number must be not over thirty 
thousand per cubic centimeter. Certified milk is the safest and best milk 
obtainable for use in infant feeding, and can now be had in most large 
cities and in some small ones. There is no reason why it should not be 



112 DISEASES OF CHILDREN. 

obtainable anywhere. Any progressive dairyman or farmer can produce it. 
The price of this milk is 50 to 100 per cent, higher than that of ordinary 
bottled milk. 

It is important that the certification be done by some competent medi- 
cal authority, and no milkman should be allowed to do his own certifying. 

Pasteurized and Sterilized Milk. — By heating the milk to about 
160° F. for about twenty minutes the great majority of bacteria present 
are destroyed. Such treatment of milk is called pasteurization. If the 
milk is heated to 212° F. it is said to be sterilized, as all of the bacteria 
are destroyed. In both of these processes the bacterial spores survive, and 
if the milk is not kept below 50° F. they will germinate, and soon the milk 
will contain as many bacteria as it did originally, but the type or kind of 
bacteria will not be the same. Bacteria that convert the sugar of milk into 
acid and cause souring are the predominating kinds in fresh milk, and the 
acid they produce retards the growth of other types, until, when milk is 
nearly soured, 95 per cent, of all the bacteria present are acid producers. 
Heating the milk to about 150° F. destroys the acid bacteria and leaves 
a free field for bacteria that attack proteins. Therefore pasteurized or 
sterilized milk does not readily sour, but its proteins are often partially 
decomposed by bacteria produced from spores which escaped destruction, 
and such milk may cause considerable digestive disturbance. Pasteuriza- 
tion or sterilization may be used to take the place of cleanliness in produc- 
ing milk, but it is not to be advocated for this purpose. If the milk is 
suspected of containing pathogenic bacteria, then it should be pasteurized, 
but this should be done at the dairy, so that there shall be no oppor- 
tunity for contamination between the time the milk is bottled and the 
infant receives its food, for pasteurized milk is just as liable to be unhealthful 
as fresh if it is not protected from reinfection. Sterilized milk is not used 
to any great extent because it has a cooked taste. Pasteurized milk tastes 
very much as fresh milk does, although a difference is discernible. Heating 
milk in some way alters it so that it is not solidified by rennin as quickly 
as fresh milk, and this property is often taken advantage of in preparing 
food for infants in whose stomachs fresh milk solidifies too rapidly. Heat- 
ing the food may make it digest satisfactorily. 

Milk for the general bottled trade will contain between 3.5 per cent, 
ami 4 per cent, of fat, about 3.20 per cent, proteins, and 5 per cent, sugar 
anrl mineral matter. Bottled milk from fancy Jersey cattle will contain 
from 4.5 per cent, to 5.5 per cent, fat, 3.5 per cent, proteins, and 5 per cent, 
sugar anrl mineral matter. Certified milk generally contains 4 to 5 per 
cent, of fat, with the other ingredients about the same as in good bottled 
milk. 



PRINCIPLES AXD -MATERIALS USED IN SUBSTITUTE FEEDING. 



113 



Cream. — There are two kinds of cream sold by milk dealers; (1) 
gravity cream, or that which rises naturally if the milk is allowed to stand ; 
(2) centrifugal cream, or that which is separated by passing the milk 
through a centrifuge running at a high rate of speed. The percentage 
of fat in cream varies, running all the way from 16 per cent, up to 40 per 
cent. Some gravity cream may run as low as 16 per cent, and as high as 
25 per cent. Centrifugal cream can be made of any desired percentage of 
fat by adjusting the centrifuge. There are marked physical differences 
between gravity cream and centrifugal creams. Centrifugal cream is much 







Fig. 33. — Microscopic appearance of normal milk. 
Fat globules in clusters. 



(Bahcock and Russell.) 




Fig. 36. — Microscopic appearance of centrifuged, or heated milk. 
(BabcocJ: and Russell.) Fat globules not in clusters. 



114: 



DISEASES OF CHILDREN. 



thinner than gravity cream of the same composition. Figs. 35, 36 show 
the microscopic appearance of normal milk and milk that has been 
centrifuged or heated. 

Condensed Milk. — There are on 
the market, and widely used, a large 
number of brands of condensed milk. 
These are made by evaporating milk in 
vacuum pans, at a low temperature, 
after it has been brought near the 
boiling-point. If it is to be sold in 
the fresh state it is then run into 
cans and shipped to market. Other- 
wise, granulated sugar is added and 
the milk- is then put into small cans 
and hermetically sealed. Such milk 
is known as sweetened condensed 
milk. It is a one-sided diet contain- 
ing an excess of carbohydrates. It 
will make children very fat because 
they change its excess of sugar into 
body fat, but when it is diluted so 
they can digest it the percentage of 
proteins or blood and muscle-forming 
portion of the food is not much more 
than half that of mother's milk, and 
of course the infant cannot grow prop- 
erly on it. There is also a great de- 
ficiency in fat. 

Evaporated Milk. — There is also 
sold in cans what used to be called 
" evaporated cream " but which 

since the passage of the " Pure Food and Drugs Act" in 1906 is called by 
its true name " evaporated milk." This is condensed milk which has been 
canned without the addition of sugar. It has a creamy consistency and 
when diluted with water is very much like sterilized milk. It does not sour 
readily, but is liable to putrefaction, and for this reason is put up in small 
cans that must be used up soon after opening. It will not keep when 
opened as will the regular condensed milk. 




Fig. 37.— Obesity with lack of 
proper musculature, resulting from 
high carbohydrates and low pro- 
tein. 



PRINCIPLES AND MATERIALS USED IX SUBSTITUTE FEEDING. 



115 



Mammala. 

Mammala is a dried milk prepared from whole milk from which a 
portion of the cream has been removed, and some milk sugar added. It is 
dried by the Hatmaker process at a temperature of 280° F. 

It should be regarded as a substitute for cow's milk, especially where a 
wholesome product is not available or for purposes of traveling, as it keeps 
well and no refrigerator is required. 

It is prepared by dissolving the required amount for each feeding in 
hot water. Xo extra sugar is needed. 

Mammala contains approximately : 



Fat 

Proteins . . 
Milk Sugar 

Ash 

Water 



12 


12 


24 


35 


55 


34 


4 


93 


3 


2« 



100.00 

Cereals. 

The various cereals play an important part in artificial infant-feeding, 
and when used intelligently are of great service. In feeding sick infants and 
for tiding over a period when milk is not tolerated, the cereals and products 
derived from them are the main reliance. But it should also be remem- 
bered that if used injudiciously they may cause considerable disturbance. 

General Properties of Cereals. — ■ 
All cereals are composed of fats, car- 
bohydrates, proteins, and mineral 
matter in different proportions. The 
amount of fat in wheat flour is about 
1 per cent., while the quantity in oat- 
meal is about 9 per cent. Barley 
flour may contain as high as 3 per 
cent, fat, while pearl barley will con- 
tain as little as 0.7 per cent. fat. 
Their proteins vary in much the same 
way. Barley flour may contain as 
high as 13 per cent, and as low as 7 per cent, proteins. These differences 
are largely due to the methods of preparing the cereals for use. Fig. 38 
is an illustration of a cross section of a cereal in which it will be noticed 
that the proteins are found in the outer layers of the grain. In making pearl 
barley the outer layers are ground off, leaving the interior portion which 
contains a relatively high proportion of carbohydrates or starch. Accord- 
ingly, a sample of barley may contain 13 per cent, proteins and 74 per cent. 
carbohydrates, and after it has been "pearled" it will contain 7 per cent. 




Fig. 38. — Barley grain. (Good ale.) 
e, Protein layer; d. starchy portion. 



116 DISEASES OF CHILDREN. 

proteins and 77 per cent, carbohydrates. The proteins of barley make an 
exceedingly sticky dough when the flour is mixed with water, and for this 
reason it is desirable to remove a portion of the protein for certain purposes 
in cooking and some flour is made from barley from which the protein layer 
has been removed. Such flour stirs into water very easily and for cooking 
purposes is very convenient. From a nutritive standpoint such flour is 
not the best, as in infant-feeding particular^, the main object is to give 
as much proteins as can be utilized, and cereals containing the full quantity 
of protein are to be selected. 

Carbohydrates of Cereals.— The skeleton and tissues of plants are 
composed of carbohydrates, while in animals the tissues are mostly proteins. 
Naturally, then, the cereals are composed largely of carbohydrates, the 
proteins which are only necessary for the formation of new protoplasm being 
present in smaller amounts. The carbohydrates may be in a number of 
forms, and the plant and its germ has the power to change one form into 
another as is needed. When the reserve or starch is drawn upon the starch 
first becomes soluble, and is then changed into dextrin and finally into 
maltose. These changes can readily be brought about in preparing food 
for infants, and this fact is of importance, for oftentimes carbohydrates in 
the form of starch will not be acceptable, when by being converted into 
soluble starch, dextrin, or maltose they will not only be well digested, but 
will bring about a marked improvement in general conditions. Many of 
the proprietary infant foods are made in whole or in part of cereals which 
have been treated so as to affect the properties of their carbohydrates, or 
starch. Details for preparing cereals for infants will be found on page 136. 

Eggs. 
Eggs. — These are to the animal kingdom what the cereals are to the 
vegetable kingdom — a germ with material which it can use in forming 
an animal organism which is capable of digesting food from other sources. 
As the animal tissues are almost entirely made up of proteins and water, 
eggs naturally are likewise composed principally of proteins and water. 
They also contain fat, and lecithin from which nerve tissue may be formed, 
and organic iron for blood formation. Eggs of different animals vary in 
composition according to the development of the young when hatching takes 
place Hen's eggs are the ones principally used and these contain enough 
of the food elements in suitable form to make all kinds of tissues. 

Eggs, therefore, are very useful additions to diet during the growing 
period, and especially when the infant is beginning to eat table food and 
needs easily digested proteins. 



PRINCIPLES AND MATERIALS USED IN SUBSTITUTE EEEDING. 117 

Dextri-Maltose. — This is a preparation of malt-sugar consisting of 
maltose, 51 per cent.; dextrin, 47 per cent.; sodium chloric!, 2 per cent. 
Each ounce has a food value of 110 calories. It is a readily absorbable 
sugar containing no cellulose, fats or proteins. It often agrees better than 
milk or cane sugar, and is especially indicated in infants in whom it is 
desired to get an increase in weight without causing sugar disturbance. 

Proprietary Infant Foods. 

General Properties. — Before the subject of infant-feeding was as 
well understood as it is at present, many attempts were made to furnish 
artificial foods which should take the place of mother's milk and of cow's 
milk. For a time they served a useful purpose and when it was impossible 
to obtain a supply of good cow's milk they were of considerable value, as 
very often they were retained and saved the infants from starvation or 
serious digestive disturbance caused by contaminated milk. On them many 
infants gained in weight and thrived temporarily, but frequently these 
infants developed rickets and scurvy, or were poorly developed and of feeble 
constitution, and consequently were carried off by the first serious sickness. 
All of these foods are composed of proteins, mineral matter, fats, and carbo- 
hydrates. In some the amount of fat is infinitesimal, the protein low in 
quantity and the carbohydrates very high. None of them are at all like 
mother's milk in properties. They often contain only enough protein to 
but little more than make up for metabolic waste, but the carbohydrates 
are in such a form that they are easily assimilated and converted into fat 
which causes increase in weight. 

All of the proprietary infant foods are composed of cereals, sugars, 
dried milk, and eggs, either singly or in combinations that have undergone 
special treatments. Chemical analyses show little or none of their proper- 
ties except their possible nutritive value. 

Classification of Proprietary Infant Foods. — A clear idea of what 
the infant foods on the market are like will be obtained if they are classified 
according to the materials from which they are made, and according to this 
plan they will all fall into about three or possibly four distinct groups or 
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120 DISEASES OF CHILDREN. 

The composition of the food when it is in the infant's bottle will 
depend absolutely on how much of the proprietary food is used or on the 
richness and quantity of milk to which it is added. Thus it is manifestly 
impossible to give analyses which will give a correct idea of the nutritive 
value of these mixtures. 

There is one point, however, which should become fixed in the mind 
and that is that nearly all of the proprietary foods are composed of carbo- 
hydrates mostly, and these carbohydrates are largely if not entirely derived 
from cereals. Gain in weight is often made on these foods, but unless they 
are reinforced by milk the tissues are not of the firm muscular character 
produced by foods richer in proteins. 

Sometimes, as when traveling or when a good quality of milk cannot 
be obtained, the foods that are to be used without fresh milk "may serve a 
useful purpose. But for general purposes of feeding these foods possess 
disadvantages over food mixtures for which the physician can write pre- 
scriptions to be followed by the mother or nurse, after he has become 
familiar with the principles and methods of artificial feeding, 



CHAPTER XIY. 

RISE AND DEVELOPMENT OF SCIENTIFIC 
INFANT-FEEDING. 

Historical. — The experience of many successful pediatricians in all 
parts of the world showed that infants did much better, as a rule, if part 
of their food was fresh milk of some kind, but it was also found that there 
was no animal that secreted milk having exactly the same properties as 
human milk. Therefore attempts were made to make cow's and goat's 
milk, which were the milks most available, correspond to human milk in 
composition and properties. Human milk was analyzed, as were also the 
other milks, and it was found their composition was apparently the same, 
except that the proportions of the ingredients varied. Cow's milk was richer 
in protein which formed curds in the stomach ; thus arose the process of 
diluting milk for infant-feeding. It was found that diluting the milk 
with gruels made from cereals increased its digestibility by softening the 
curds. Later, it was discovered that if milk was peptonized the curds would 
not form, or if the milk was only partially peptonized the curds formed were 
very small, and peptonized milk for infants was looked upon as the solution 
of the problem. The action of bacteria on milk was recognized, and then 
sterilization, heating milk to 212° F., was introduced. After a time it was 
observed that sterilizing unfavorably affected the milk, and pasteurization or 
heating the milk from 150° to 165° F. was introduced. These processes 
did a great deal of good under certain conditions, but the problem was not 
yet completely solved. 

After a time it was taught that all milks were composed of the same 
substances, and that their differences were due merely to different per- 
centages of the various ingredients and unlike reactions. Subsequently a 
new theory was brought forward, that the difference between human milk 
and cow's milk was due to the relative proportions of casein (the portion 
of the protein which is solidified by rennin) and albumin present in each, 
but this theory has been seen to be untenable, as it was found that caseins 
differ in properties and that the term casein is about as specific as the 
term wood. 

Since the subject of infant-feeding has been approached from the 
biological standpoint, the fallacy of the theory of making human milk from 
cow's milk has become quite apparent. 

Fundamental Errors Made. — When the theory was put forth that 
the differences between human milk and cow's milk were due to unlike 

121 



122 DISEASES OF CHILDREN. 

percentage composition and reaction to litmus, two important errors were 
made. In determining the comparative properties of the solids made from 
the proteins of the two milks, acid was added to the milks, and rennin, or 
the gastric secretion of young animals with which the milk would come in 
contact in the stomach, was rejected as being an unsatisfactory reagent. 
The effect on milk of adding acid is totally different from that produced 
by the addition of rennin. The milk does not meet enough acid in the 
young stomach to precipitate it but rennin which solidifies it is present; 
so this basis of comparison was not only erroneous, but misleading. Acid 
will make a fine precipitate, while rennin makes a solid mass from cow's 
milk. 

When lime-water is added to cow's milk it alters the casein so that 
it will not form a solid with the rennin of the stomach. 

Litmus is not a proper indicator to use in taking the reaction of milk 
as it is an acid itself, stronger than some of the acids of milk, the presence 
of which it fails to show. 

For testing the reaction of milk, phenolphthalein (1 per cent, alcoholic 
solution) should be used instead of litmus, and with this indicator breast- 
milk is also found to be acid in reaction. The effect of adding lime-water 
is to modify the physical and digestive properties of the casein in the 
infant's stomach. 

The alkalies are now used with a better understanding of their action 
and effect and their routine use is not considered as advisable as formerly. 

Similar errors were made in the theory that the differences between 
human milk and cow's milk were due to unlike percentages of casein and 
albumin, which were supposed to be constant for each kind of milk. It has 
been stated with great confidence that there was one part of albumin to 
five parts of casein in cow's milk and two parts of albumin to one part of 
casein in human milk. Van Slyke, who has made an exhaustive study of 
this subject, found there was no fixed relation between casein and albumin. 
It varied in herd milk from 2.6 to 5.6 parts of casein to one part of albumin. 
The proportion is different in the various breeds of cows and in the indi- 
viduals of the breeds, and it also is different at different seasons of the 
3'ear. In two Jersey cows the proportions were 3.7 and 6.3 parts of casein 
to one of albumin, and in two Holstein-Friesian cows they were 3.2 and 
4.4 to 1. 

In addition to these wide fluctuations it should be remembered that 
caseins are not alike, so this basis has an insecure foundation to rest upon. 
In practice, when this theory is applied, a portion of the casein of the cow's 
milk is removed and alkali is added to the remaining amount which throws 
it into the intestine for digestion. 



RISE AND DEVELOPMENT OF SCIENTIFIC-FEEDING. 123 

These different methods of supposedly making human milk from cow's 
milk have all fallen under the heading of " modifying milk." As a- matter 
of fact, none of the methods resulted in making human milk, and some of 
them were wide of the mark. Those who study the subject carefully will 
see that what actually takes place in all of the methods of feeding which 
have been proposed is an adaptation of the food to the infant by one means 
or another. Milk is modified by all methods, but the principles involved 
differ widely. The following classification will be found helpful: 

Classification of Methods of Modifying Milk for Infant-feeding. — 
Any method of infant-feeding,- no matter what theory it is founded upon, 
will fall naturally into one of the following groups. This classification will 
not only help the reader to understand any method of feeding which he 
has used, but will readily help him determine the principles involved in 
any new plan or method of feeding which may be proposed in pediatric 
literature. 

Group 1. Methods that affect the quantitative composition of cow's 
m ill'. 

(a) Simple dilution with water; (&) dilution with water with the addition 
of cream and sugar; (c) removal of a portion of the casein by adding rennin and 
then straining out the solidified casein or a portion of it. 

Group 2. Methods in which the character of the proteins of cow's 
milk are so altered that the rennin of the stomach will not solidify the milk. 

(a) Addition of lime-water until alkaline to phenolphthalein (5 to 10 per 
cent, of the food) ; (6) addition of carbonate of potassium until slightly alkaline 
(I grain to ounce of milk). If the stomach secretes enough acid to neutralize 
these additions the milk will solidify. 

Group 3. Methods that retard the solidification of milk by rennin and 
also neutralize any acid that may be secreted by the stomach. 

(a) Addition of 1 to 2 grains of bicarbonate of sodium to each ounce of food : 
(b) addition of syrup of lime; (c) addition of magnesium hydrate. These addi- 
tions tend to prevent all gastric digestion and to throw the entire work of digestion 
on the intestines. 

Group 4. Methods in which the casein is precipitated in fine particles 
by acids. 

(a) Buttermilk feeding; (&) kumyss feeding; (c). matzoon feeding; (d) 
addition of dilute hydrochloric acid. In buttermilk feeding, lactic bacteria 
naturally in the milk, or those that may be added, are allowed to grow and produce 
lactic acid which precipitates the casein. If the buttermilk is boiled before feed- 
ing, as it is sometimes, the bacteria will be killed, otherwise bacteria are also 
given in enormous numbers which may sometimes prove beneficial. In kumyss 
and matzoon feeding, bacteria produce acid which precipitates the casein. Yeasts 
may also be present. 

Any pepsin that may be secreted can readily act upon the proteins in the 
presence of the acids. Such foods may encourage gastric digestion. 



124: DISEASES OF CHILDREN. 

Group 5. Methods that profoundly alter the character of the milk. 

(a) Peptonization of milk; (h) addition of 1 to 2 grains of citrate of sodium 
or potassium to each ounce of milk employed. 

Peptonization completely alters the character of the proteins of the milk. 
Casein is in some way combined with calcium in milk. Citrate of sodium or 
potassium when added to milk produce citrate of calcium and casemate of sodium 
or potassium, which will not form a solid with rennin. The calcium citrate is 
soluble in an excess of the precipitant and remains in solution. Acids added to 
milk in which the casein is in combination with ammonium, sodium, potassium, 
or lithium will produce a precipitate of casein like that of sour milk. Peptonized 
milk also remains fluid in the stomach. 

Group 6. Methods that indirectly alter the properties of the milk. 

(a) Sterilizing, boiling, or scalding the milk; (&) pasteurizing the milk; 
(c) using condensed or evaporated milk. 

Heating milk in some way changes it so the rennin ferment does not cause it 
to solidify as firmly or as promptly as does fresh milk, and it also destroys bac- 
teria that might produce acid which would accelerate the action of the rennin in 
solidifying the milk. 

Group 7. Methods that mechanically alter the character of the 
solidified milk without affecting the action of the digestive secretions. 

(a) Diluting the milk with cereal gruels in which the starch is in a gelatin- 
ized condition; (6) diluting the milk with cereal gruels in which the starch has 
been converted into soluble starch, dextrin, and maltose. 

Infants Tend to Adapt Themselves to Their Food. — One of the 

inherent faculties possessed by all forms of living things is the ability to 
change their form and functions, to bring themselves into harmony with 
new or altered conditions of life, if the altered conditions are brought about 
gradually. The acquirement of tolerance for drugs, and immunity to 
certain diseases after one infection are illustrations. 

Similarly, the feeding or nutritional habits of animals can be modified 
to a greater or less extent. It is possible by careful management to develop 
in a carnivorous animal herbivorous habits of feeding. The one thing to 
be avoided in such feeding is too radical and too sudden changes in the 
form of the food, as the animal then does not have sufficient time to adapt 
itself to the new conditions. 

In infants this ability of adaptation to the food is present to a marked 
degree, and much of the credit that goes to the successful feeder is due to 
the unconscious cooperation of the infant, brought about by making the 
changes in food gradually, giving it time to adapt itself to new food condi- 
tions. Those in which the power of adaptation is dormant form the 
greater number of the difficult feeding cases. 

It is also due to this power of adaptation that some infants can survive 
and grow on food that would sicken other children. There is a limit to 



RISE AND DEVELOPMENT OF SCIENTIFIC-FEEDING. 125 

this faculty, however, and it is more strongly developed in some infants 
than in others. When properly utilized it is of great assistance to the 
physician, but it should not be abused. 

Infants Differ in Digestive and Assimilative Efficiency. — It has 
been often observed that some infants will thrive and gain in weight on 
an amount of nutriment that others of the same age fail to gain on, and that 
some infants gain in weight more rapidly on the same quantity of food 
than other infants do. This fact has been perplexing to many, and has 
led some to believe there was no science in infant-feeding, each infant being 
a law unto itself. But widely extended experiments on animals have shown 
that they differ greatly in their efficiency in appropriating and utilizing 
food, the organs of assimilation being nearly twice as efficient in some 
animals as in others of the same species. 

Assimilation Most Efficient in Early Infancy. — The capacity for 
assimilation of food is not the same at all periods of growth. It is greatest 
during the early part of infancy and becomes gradually less as maturity is 
approached, until no matter how much food is eaten only the normal 
metabolic loss is made good, and fat is stored up, any excess of proteins 
being excreted. Young infants have been found to store up 70 per cent, of 
the proteins of their food, but in the adult as much nitrogen as is taken in 
as protein is excreted, so none is fixed as new tissue. Therefore a sufficient 
quantity of tissue-building food (protein) early in life is of the greatest 
importance from a point of economical use of food and for promoting vig- 
orous growth. It is also important in another way, for at this period the 
digestive organs, liver, kidneys, and heart are developing rapidly, and the 
size and strength of these organs will depend upon the supply of building 
material available, which is protein. 

If an infant has indigestion its food should be reduced to its digestive 
capacity, but no greater mistake is made in infant-feeding than to keep 
infants on food containing a small quantity of protein for any length of 
time, for as the infant becomes older, increasing the quantity in the food 
is offset by the lessened capacity of assimilation. Proper feeding in the 
first few weeks or months after birth insures good development and freedom 
from trouble later on. Tf an infant is badly fed during this formative 
period, its management later on may be a tedious and difficult matter. 



CHAPTEE XV. 
PRACTICAL FEEDING. 

Basis of Practical Feeding. — No matter how much the actual 
processes employed in preparing food for infants may differ, they all have 
for their object the combination of protein, mineral matter, fats, carbo- 
hydrates, and water in some form that will be acceptable to the infant. 
It has been shown that it is important for these ingredients to be present 
in the food in certain relative proportions if the infant is to develop 
properly, and with the least amount of waste of digestive and assimila- 
tive effort. It is likewise of importance to understand methods of calcu- 
lating the quantities of the food elements in any food mixture, and how 
to determine the quantities of milk, cereals, sugar, and other materials 
necessary to use to produce different food mixtures containing any desired 
quantities of protein, mineral matter, fats, carbohydrates, and water. The 
best practice is to think of the percentage composition of the food, and 
many times the cause of a digestive disturbance in an infant can be deter- 
mined by working out the approximate percentage composition of the food 
from the formula used in making it, when it may be found that one or more 
ingredients — that is the proteins, fats, or carbohydrates — are present 
either in excess or in too small quantity. 

Percentage Milk Mixtures in Infant-feeding. — As was stated on 
page 110, the best milk to use in feeding infants is that produced under 
sanitary conditions, bottled at the dairy and kept iced until delivered to 
the family. When such milk is delivered the cream has risen and appears 
as a distinct layer at the top of the bottle. If the bottle of milk is shaken 
to mix its contents, the milk will then have a uniform composition which 
will almost always fall between the following extremes: 

Fats Carbohydrates Protein Mineral matter 

3%-5% 4%-6% 3%-3.5% 0.6%-0.8% 

To make simple approximate calculation of the quantities of these 
elements that cow's milk imparts to a mixture, it is best to take the mean 
composition of commercial cow's milk as" a working basis, especially as a 
large part of the bottled milk has about this composition. If milk above 
this mean is used the error cannot be great, and if below the error will also 
be small. For this reason it is advisable to take as a working basis the 
following figures : 

Fats Carbohydrates Protein Mineral matter 

4% 5'% 3.2% 0.7% 

Note. — At one time the figures proteins 4%, fat 4%, and carbohydrates 4% were 
used but as the error in proteins was about 25% they are not being used so much. Some 
still take the protein as 3.5%, but this is rather high for the general run of milk. 

126 



PRACTICAL FEEDING. 



127 



If a feeding mixture contains one-fourth milk, the quantities of the 
food elements supplied by the milk will be one-fourth of the foregoing 
figures or: 



Fats 
4[4%_ 



Carbohydrates 
5% 



Proteins 
3.2% 



Mineral Matter 
0.7% 



1% 1.25% 0.80% 0.18% 

If the proportion of milk in the food was one-third, one-half, one-tenth, 
or any other fraction, the composition of the food would be determined in 
the same manner. 



DISTRIBUTION OF FAI IN OT 
BOTTLE DF4XMIUC.EM:HQI, 

REMOVED WITH DIPPER 




LAYER OF CREAflrf 

NOT UNIFORM IN 
COMPOSITION 



FAT IN DIFFERENT PORTIONS 

REMOVED FROM THE TOP 

AND MIXED. 



2nd OZ. TOP 2 02S.MIXED 24 $ FAT 



22.5# " 
21.45* " 
19.2#" 
16.8#«* 
15.0* " 




Fig. :>0. — Percentages of fat in different portions of a quart bottle of milk. 

Top Milk. — "When whole milk is diluted for infant-feeding the pro- 
portion of fat in the diluted milk may fall below the requirements, as 
also the quantity of sugar or carbohydrates, so it may be necessary 
to add these elements. The quantity of protein in cow's milk is too great 



128 DISEASES OF CHILDREN. 

for most infants to digest, and more than they require for growth, and 
therefore it is to reduce the quantity of proteins that the milk is diluted. 

Formerly the addition of cream to diluted milk was a favorite method 
of adding fat, as it is essentially milk extra rich in fat, the protein and 
carbohydrates being present in but slightly less quantities than are found 
in whole milk. However, several objectionable properties of cream make its 
use inadvisable. First, its composition is not uniform, and then it may be 
old and heavily laden with bacteria which will infect any sanitary milk it 
may be mixed with ; and, again, it may have been passed through a centri- 
fuge, and had its natural emulsion destroyed (see page 113), so that it- 
becomes more oily. In addition to these material objections, it is a difficult 
matter for many to calculate the composition of food made with cream and 
milk, and great errors in the composition of the food result from mistakes 
in the arithmetical process, the infants often suffering from the improper 
food. 

These drawbacks to the use of cream have caused this method of adding 
fat to the infant's food mixture to be largely supplanted by the top-milk 
method, which is simple and accurate. 

As was stated above, when milk is bottled and kept cool the cream rises 
to the top of the bottle and forms a distinct layer. This cream contains 
nearly all of the fat of the milk, the milk under the cream layer often con- 
taining only 0.4 per cent, of fat, while the cream at certain levels may 
contain as high as 25 per cent, of fat. The layer of cream is not uniform in 
composition, as will be seen by the illustration of the amount of fat in 
each ounce removed from the top of a quart of milk containing 4 per cent, 
of fat even on which the cream had not completely risen, as is shown by 
the high percentage of fat in the milk under the cream layer. 

At one time it was believed that cream which rose of its own accord, 
and known as gravity cream, was uniform and contained but 16 per cent, 
of fat; and as very often the cream to be added to the infant's food was 
taken directly from the mouth of a quart bottle, instead of the infant getting 
16 per cent, fat cream, one containing 25 per cent, or more of fat was 
obtained. A common thing was to see infants suffering from fat indigestion 
caused by an excess of fat thus unwittingly introduced into the food. 

It is evident that if all of the fat of a quart of whole milk containing 
4 per cent, of fat rose to the surface, the top or upper pint, or one-half of 
the quart of milk, would contain twice the percentage of fat in the original 
milk, or 8 per cent., while the remaining pint would contain no fat at all. 
If all of the fat was in the top one-third of the quart of milk it would con- 
tain three times 4 per cent, or 12 per cent, of fat. 



PRACTICAL FEEDING. 



129 



As a matter of fact, nearly all of the fat in a quart of milk is found in 
the top six to eight ounces after the cream has risen, so by taking all of this 
layer of cream with some of the fat-free milk underneath, milk containing 
1J, 2, 3, or any other number of times as great a percentage of fat as the 
whole milk contained may be had from the ordinary quart bottle of milk. 
As a small percentage of fat remains in the milk below the cream, a little 
less than the above theoretical quantities are removed from the top of the 
bottle. 






Fig. 40.— Quart bottle of milk 
showing layer of cream. 



Fig. 41. — • Cliapin 
cream dipper. 



These top milks, as they are called, contain about the same quantities 
of protein, mineral matter, and carbohydrates as whole milk, so when using 
whole milk or top milks for dilution the percentages of all the elements 
except the fat will be the same no matter which is diluted. Therefore, by 
using definite quantities of the upper part of a quart of milk after the 
cream has risen the amount of fat in the diluted milk can readily be varied, 
while the percentages of the other elements remain unchanged. For ex- 
ample, there could be obtained top milks containing 

Protein 
3.29? 
3.2% 
3.29? 



Fat 


Carbohydrates 


3% 


5% 


894 


*% 


29? 


59? 



130 DISEASES OF CHILDREN. 

And if each was diluted four times the diluted milk would contain percent- 
ages equal to one-fourth of these figures, or 



Fat 


Carbohydrates 


Protein 


1.5% 


1 . 25% 


.80% 


2.0% 


1 . 25% 


.80% 


3.0% 


1 . 25% 


.80% 



The percentages of the elements in any dilution can readily be de- 
termined in the same manner. 

To obtain these different top milks the dipper 1 shown in Fig. 41 is 
used. It measures one ounce. 

Percentage Cereal Gruels. — Until comparatively recently the use of 
cereal gruels has been purely empirical, and little attention has been paid 
to their composition or nutritive value. But recognition of the benefits to 
be derived from their intelligent employment is leading to their being used 
in a scientific manner, and the tendency is to prescribe them in definite 
quantities and of approximately definite percentage composition. The com- 
position of cereal gruels depends upon the cereal employed in making them 
and also to a much greater extent upon the condition of the cereal, that is, 
whether it is in the form of flour, granulated, or in the whole state. If 
flour is used in making the gruel and none is removed by straining, dividing 
the composition of the flour by the number of parts of gruel made from 
one part of flour will give its composition; as, for instance, a gruel made 
with one ounce of flour to the pint would be one-sixteenth as strong as 
the flour. But when whole or granulated cereals are used, a large part of 
the proteins and considerable of the carbohydrates are removed by strain- 
ing, as the cereal does not disintegrate while cooking and the composition 
of the gruel is not in proportion to the composition of the cereal employed. 

In using ordinary cereals in preparing gruels the following quantities 
will be approximated, when a tablespoon is used in measuring the cereals. 

1 level tablespoonfnl of pearl barley weighs i oz. avoirdupois. 
1 level tablespoonful of barley flour weighs I oz. avoirdupois. 
1 level tablespoonful of wheat flour weighs i oz. avoirdupois. 
1 level tablespoonful of rolled oats weighs \ oz. avoirdupois. 

If all of the rolled oats had remained in the gruel made with one ounce 
to the quart, the gruel would have contained about 0.50 per cent, proteins, 
as these rolled oats contained about 16 per cent, proteins, but the gruel 
actually contained but 0.26 per cent, proteins, showing half the proteins 
were removed when the gruel was strained. 

i It is known as the Chapin Dipper and is sold through the wholesale druggists. 
It can be obtained by mail of Cereo Company. Tappan, N. Y. ; also from Jas. T. 
Dougherty, 411 West Fifty-ninth St.. New York. 



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132 DISEASES OE CHILDREN. 

Outline of Feeding Directions.— . It is impossible to give explicit 
directions for preparing food for each particular infant, as infants differ in 
their digestive capacity, in their efficiency in assimilating food, and in 
their condition when the physician is called in. However, all cases naturally 
fall under about four headings: (a) Well infants which cannot obtain 
breast-milk, and the control of which the physician has from the start. 
(&) Infants that are well except that they are suffering from bad methods 
of feeding, (c) Infants of feeble constitution whose digestion is easily 
deranged, (d) Infants that are acutely ill. Before attempting to feed an 
infant, its feeding history should be carefully taken to determine in which 
class the infant belongs. 

The methods of feeding these different classes of infants vary con- 
siderably, and while the same general principles hold, they must be applied 
differently. In all methods attention must be paid to percentage com- 
position of the food. This is not a difficult matter, and can be readliy 
learned, but the skill and ability of the infant feeder have a chance for 
display when it comes to adapting the form of the protein, fats, and carbo- 
hydrates to the infant ; or to modifying the action of the infant's digestive 
secretions on its food by various additions to the food as explained on 
page 123. In the suggestive feeding mixtures given here the preparation 
of the food is sharply divided into two parts : First, adjustment of the 
quantitative or percentage composition. Second, modification of the form 
of the food, or the action of the digestive secretions on the food. 

Food for Healthy Infants. 

The object in preparing food for healthy infants is to so modify or 
adapt the food that they will be well nourished and have their digestive 
organs so developed that the infants will become able to take whole cow's 
milk without digestive disturbance. It is generally about the ninth to 
twelfth month before this is possible, and if alkalies or antacids have been 
added to the food in too great quantities it may be later, as these substances 
seem to interfere with the normal development of the stomach. 

In reality the whole process amounts to a training of the infant's 
digestive organs, and it is important to commence in the early months with 
small quantities of the protein of cow's milk, as this causes the greatest 
amount of trouble, moderate quantities of fat, and a liberal supply of 
carbohydrates, as these cause little digestive disturbance when not given in 
too great excess. The fats are kept in the neighborhood of 2~3 per cent, 
during the whole period of artificial feeding, and the carbohydrates at 
about 6 per cent, or 7 per cent., seldom over these figures. But the protein 
is managed in an entirely different manner. At first the protein is given 



PRACTICAL FEEDING. 



133 



m as sm 



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is no fixed rule, except to increase 
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"With some the advance can be quite 
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made slowly. 

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tity of protein in the food it is often 
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less the speed. 

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outline of the quantities and compo- 
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as a working basis in preparing food 
for healthy infants by the top milk 
method. 



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PRACTICAL FEEDING. 



135 



It will be noticed in the feeding table that less sugar is to be added to 
the food when gruel is used than when water diluent is employed. This is 
because the gruel contains considerable carbohydrates. A convenient rule 
to remember is, when gruels made with one ounce of flour to the quart 
are used, add 3 per cent, of sugar; and when two ounces of flour to the 
quart are employed, add 2 per cent, of sugar. These additions would be 
one thirty-third and one-fiftieth of the total quantity of the food, respect- 
ively. These proportions will always make the percentage of carbohydrates 
in the food between 6 and 8 per cent. 




Fig. 43. — Simple utensils for home modification. 



A rule often employed for adding sugar to food is, add 5 per cent, 
or one part to twenty parts of food. This will always make the percentage 
of carbohydrates fall between 5.5 per cent, and 9.5 per cent, when water 
diluent is used and much higher when gruel diluent is employed. One part 
of sugar to twenty-five parts of food makes the percentage of carbohydrates 
fall between 5 per cent, and 8 per cent, when water diluent is used. 

When gruels are used to dilute the milk the percentages of protein in 
the mixtures will be greater than those given in the feeding table which 
are for milk and water mixtures. The protein added by the gruel not only 
increases the tissue-building value of the mixtures, but acts as a mechanical 
diluent or softener of the solid formed from the protein of the cow's milk, 
and hence makes it more digestible. As the value of gruels when used 
intelligently ha? become better appreciated, they have come to be employed 
mo^e and more, and whenever thev are tolerated thev should be used in 



136 DISEASES OE CHILDREN. 

preference to water for diluting the milk. Two kinds of gruels are em- 
ployed: (a) those made by boiling the cereal in water, which contain 
starch in an unchanged condition; (&) those to which an agent for chang- 
ing the starch into dextrin and maltose is added. Gruels so made are 
called, respectively, plain gruels and dextrinized gruels. Dextrinized gruels 
should be used for young infants and when plain gruels are not well borne. 
Directions for Making Gruels. — Stir from one to four level table- 
spoonfuls of the cereal flour into one quart of cold water to avoid the 
formation of lumps. Place the mixed flour and water into a double 
boiler (Fig. 44) and with constant stirring bring to a boil. This will 




Fig. 44. — Double boiler. 

cause the flour to swell up owing to the gelatinization of the starch. Xow 
allow the gruel to boil for fifteen minutes. Stirring will not be necessary. 
If an open kettle is used the gruel may burn at the bottom and impart a 
bad taste to the food. If the gruel is to be used plain, strain through a fine 
wire strainer and add enough boiled water to make one quart of gruel. If 
it is to be dextrinized set the cooker into cold water for two or three minutes 
and when the gruel is cool enough to taste add a teaspoonful of some 
preparation of diastase. A decoction of diastase may be made at home 
by covering a tablespoonful of crushed malted barley grains by a little cold 
water and placing the mixture in the refrigerator over night. In the morn- 
ing the water that is strained off will be active in diastase, but will not 
keep long. A glycerite of diastase known as Cereo is now made for this 
purpose, and has proven to be reliable. Stir and the gruel will become 
thinner as the starch goes into solution and forms dextrin and maltose. 
Strain and add enough boiled water to make one quart of gruel. The 
fl Occident matter in the gruel is mostly protein. No matter which kind of 
gruel is employed it should be cooled and kept on ice until ready to be 
mixed with the milk. 



PRACTICAL FEEDING. 13? 

Approximate Home Modification of Whole Milk. 

Since there are some localities in which bottled milk is not obtainable, 
it is well for the practitioner to know how he can approximately modify the 
milk when he can only assure himself that the supply is wholesome and 
obtained under cleanly precautions. 

In many isolated farming districts bottled milk is out of the question, 
and it is impracticable to have it delivered in bottles. Special utensils as 
the Chapin clipper are not ready at hand or the mother may be deemed too 
unintelligent to use them correctly. 

The principles of percentage feeding can sometimes be carried out and 
good results obtained by using very simple measures. This we have 
demonstrated to our satisfaction in our City Milk Depots where mothers in 
the tenements have been taught to modify whole milk with success as far as 
the health and growth of their infants was concerned. 

AVe have never believed that success depended upon fractional per- 
centages but rather upon percentages approximately correct made up with 
a pure wholesome milk and fed to a baby that is kept under the proper 
hygienic conditions as outlined in Chapter IV. 

The physician should be careful to select a milk from a mixed herd 
of cows and if possible avoid a milk apt to be too rich in fats, such as 
would be obtained from Jersey cows. If there is any question as to the 
richness, an examination can be made, at the nearest creamery, of the fat 
content and computations can then be based on this analysis. 

The average whole milk will contain fat, 4 per cent. ; sugar, 4 per 
cent.; protein, 3.2 per cent. If such a milk is diluted four times, that is, 
one part milk and three of diluent, we will have 

Fat. Sugar. Protein. 

4 | 4 4 3.2^ 

1 1 0.8 

1 per cent, fat, 1 per cent, sugar, and 0.8 per cent, protein in the mixture, 
which needs but the addition of sugar to make a suitable food for the new- 
born. The quantity and time of feeding will be found on page 134. 
Enough sugar is added to make 6 per cent. ; the amount is easily calculated 
if it is recollected that 1 ounce of cane sugar to every 20 ounces of the food 
will add 5 per cent. 

Similarly if a dilution of three parts is made, that is, one part milk 
arid two of diluent, we would have fat 1 1/3 per cent., sugar 1 1/3 per cent., 
protein 1 per cent., and again if the whole milk is diluted on^e. we have 
fat 2 per cent., sugar 2 per cent., protein 1.6 per cent. If three parts of 
milk are in the mixture and one of diluent, its composition will be fat 
3 per cent., sugar 3 per cent., protein 2.4 per cent. 



138 DISEASES OF CHILDREN. 

If there is any question as to the cleanliness of the milk or the health- 
fulness of the cows, the milk may be pasteurized, especially in hot weather, 
if refrigeration is not available. 

The following are simple modifications of raw whole milk made up 
with water or barley gruel and reduced to the quantity to be taken at each 
feeding. 

Baby three days to two weeks old, feed every two hours. 

Milk, 1 tablespoonful. 

Water or barley water, 3 tablespoonfuls. 

Sugar, half a teaspoonful. 

Baby, two weeks to three months, feed seven to eight feedings every 
two hours. 

Milk, 2 tablespoonfuls. 

Water or barley water, 4 tablespoonfuls. 

Sugar, 1 teaspoonful. 

Baby three to six months old. 

Milk, 6 tablespoonfuls. 
Barley water, 6 tablespoonfuls. 
Sugar, 2 teaspoonfuls. 
Six such feedings in the twenty-four hours. 

Baby six to nine months old. 

Milk, 12 tablespoonfuls. 
Barley water, 6 tablespoonfuls. 
Sugar, 2 teaspoonfuls. 
Give five such feedings in the twenty-four hours. 

Baby nine to twelve months old. 

Milk, 16 tablespoonfuls. 
Barley water, 4 tablespoonfuls. 
Sugar, 2 teaspoonfuls. 
Give five such feedings in the twenty-four hours. 

Adaptation of Food to Infant. — So far the directions have had to do 
only with bringing together the food elements in quantities capable of 
producing proper growth and development at different ages. But this is a 
small part of practical infant-feeding, for any one of the foregoing mixtures 
may not agree with the infant. The problem then becomes how to adapt the 
food so that it will agree with the particular infant. Adaptation may be 
accomplished in a number of ways, as follows, beginning with simple 
changes in the food and ending in methods that are more complex in their 
effects : 

Symptoms. — The infant has no digestive disturbances, except slight 
constipation and scanty stools, but does not gain in weight. 



PRACTICAL FEEDING. 139 

IVhat to Do. — Increase the strength of the food by using the next 
higher formula. 

Symptoms. — The infant vomits, some time after taking its food, 
rancid-smelling material; its stools are soft and contain small flecks or 
white particles. 

]Yhat to Do. — Eeduce the amount of fat in the food by using weaker 
top milk or plain milk in making the food. In extreme cases use skimmed 
milk in making the mixture and add a pinch of bicarbonate of sodium to 
each feeding. 

Symptoms. — The infant's stools are inclined to be too soft, but other- 
wise it seems to be doing well. 

What to Do. — Use barley or wheat in making gruels, and if necsesary 
use weaker top milk to reduce fat, which may be excessive. 

Symptoms. — The infant is doing well with the exception of being 
more or less constipated. 

Wliat to Do. — 'Use oat gruel for diluting the milk as it has a laxative 
effect, and increase the fat in the food to 3.5 per cent, to 4 per cent, by 
using richer top milk. Give boiled water between feedings. 

Symptoms. — The infant suffers from colic, but has no curds in the 
stools. 

What to Do. — Change the form of cereal gruel employed, and dextrin- 
ize, if plain gruel has been used. That is, if oat gruel has been used, try 
barley or wheat gruel which has been dextrinized in its place. Pasteurize 
the food temporarily. 

Symptoms. — The infant has colic with more or less curdy stools. 

What to Do. — If water has been used in making the food mixture, 
try plain or dextrinized barley or wheat gruel instead and pasteurize tem- 
porarily. If this does not overcome the difficulty, add one to two table- 
spoonfuls of lime-water to each feeding bottle ; or add one to three grains 
of citrate of sodium : or add two to ten grains of bicarbonate of sodium to 
each feeding bottle. The effect of these additions will be found at page 
124. The citrate of sodium or bicarbonate of sodium should not be added 
for long periods, as they interfere with normal digestive development. 

Symptoms. — The infant has sour, watery stools. 

What to Do. — Eeduce the quantity of sugar in the food, as it is fer- 
menting, and also change the form in which it is given. If granulated 
sugar is being used, try milk sugar. If dextrinized gruels are being em- 
ployed try plain gruels. Pasteurize. In any event change the form of the 
carbohvdrates. 



140 DISEASES OF CHILDREN. 

Food for Infants Previously Badly Fed. 

Feeding History. — These cases almost invariably have a history of 
being well nourished at birth, and perhaps of doing well at the breast until 
for some reason substitute feeding became necessary, when contaminated 
milk, improper modifications of milk, or proprietary infant foods were 
tried at random, and many or few changes in the food were made as method 
after method failed. These infants may not have gained in weight, or if 
they have gained in weight the flesh produced has been fatty, caused by 
high carbohydrates in the food with low protein. They may be suffering 
from incipient rickets, or show signs of scurvy, and in severe protracted 
cases may have drifted into marasmus. Many cases not so severe simply 
show a loss of weight with the infants in a fair condition. 

Management. — When seen early this is the simplest class of cases 
the physician is called upon to treat dietetically, and with careful manage- 
ment they promptly respond to treatment, but when the bad feeding has 
been prolonged the cases are often difficult and tedious. One of the greatest 
aids is to work out the composition of food previously given, and to consider 
the methods of adapting the food that may have been used, such as addition 
of lime-water, bicarbonate of sodium, citrate of sodium, etc. It is of 
material assistance to know what has failed and whether failure followed a 
method properly carried out or whether it followed incorrect application of 
correct principles. In this connection it may be stated again that the 
physician should understand every detail of the preparation of food by all 
methods, be able to make gruels, should know the physical properties of 
food prepared in different ways, and also be acquainted with their taste 
and flavor. Barley gruel has a slightly bitter taste, oat gruel has a dis- 
tinctive flavor, as has also legume and wheat gruel. A gruel that has been 
cooked in a stew pan often has a scorched taste which is sometimes very 
repulsive. The food may have been kept in a warm place or in a poor 
refrigerator, or the milk may have been stale or it may have been partially 
soured. Occasionally it may be found the proper top milk is not being used. 
These are a few suggestions which show that no detail of preparing the 
food should be overlooked or unknown to the physician. 

For mild cases putting the infant on a formula similar to one given on 
page 134 for healthy infants of the same age will be all that is necessary, 
although a very good plan to follow is to give the food for a younger infant 
for a few days and if it agrees a stronger formula may then be ordered. 

In more troublesome cases the digestive organs must be given a rest, 
either complete or partial, that is, no food at all must be given for a few 
hours, or the infant must be given not much more than enough food to keep 
it from living on its own tissues. 



PRACTICAL FEEDING. 141 

The following food mixtures may be tried, using whichever agrees best 
or can be prepared to best advantage, taking into consideration the prob- 
abilities of directions being carried out properly. 

Dextrinized barley, legume, oat or wheat gruel, made with one to two 
ounces of flour (four or eight level tablespoonfuls) to the quart of gruel, 
directions for preparing which will be found on page 136, or whey made as 
follows may be used: 

Directions for Making Whey. — From a quart of milk remove all 
of the cream. Then add to the skimmed milk a tablespoonful of liquid 
rennet or one junket tablet such as may be had at grocery stores. Place 
the milk in a double boiler (see page 136), and warm slowly. When the 
milk has solidified or " set " cut it in all directions into small pieces to 
allow the whey to escape. Xow warm up to about 150° F., and stir while 
doing so. The curd which was all broken up will cohere into one or more 
large pieces which may readily be removed, and about twenty ounces of 
clear whey will remain. If the whey is heated above 160° F. the albumin 
will coagulate. The whey should now be cooled and kept on ice until ready 
to be fed. Its composition will be about, protein 0.80 per cent., fat 0.30 
per cent., carbohydrates 5 per cent. 

Whey and Cream Mixtures. — In some cases mixtures of whey and 
cream are tolerated better than other forms of food. They may be con- 
veniently made as follows : 

From one quart bottle of fresh milk remove with the clipper the top 
6 ounces. Place the remaining 26 ounces in a double boiler, add a tea- 
spoonful of liquid rennet and warm slowly. "When the curd has become 
firm, cut it into small pieces with a knife and slowly bring to 150° F. 
Strain through a fine wire strainer, or cheese-cloth, and cool the whey. 

By combining the whey and the top six ounces removed from the 
quart milk bottle a great variety of mixtures may be obtained as follows : 





Use of the whey 


Approximate Composition 


I se of the top 6 ozs. 


Protein 


Fat 


Carbohydrates 


1 oz. 

2 ozs. 

3 ozs. 


15 ozs. 
14 ozs. 
13 ozs. 


.S0% 
1 . 00% 
1 . 20% 


1 % 
2.5% 
3.3% 


o% 

5% 
5% 



The quantities to be given are a little less than the amount of food 
that would be appropriate for a well infant of the same age. If any of 
these foods are well borne, milk may be added, a teaspoonful to a feeding. 
to see if it will be toleraterl. and if so a weak milk mixture may be given 
and the strength of the food increased by degrees until full strength for 
the age is reached. If rickets or scurvy is present, more care in treatment 
will he necessary, and this must be according to lines laid down under 
these titles. 



14& DISEASES OF CHILDREK. 

Food for Infants of Feeble Constitution. 

This is one of the most difficult classes of infants the physician has to 
feed, and they often tax his ingenuity to the utmost. They are generally 
the offspring of nervous parents and are easily thrown out of equilibrium. 
They catch cold easily and are subject to attacks of indigestion from trivial 
causes. During the warmer months they are readily attacked by gastro- 
enteritis, and their management then becomes tedious and their progress 
is slow, careful watching of the feeding being necessary at all times. 

Whenever possible a wet-nurse should be obtained for these cases. Arti- 
ficial feeding is unnatural in all cases, and while it may succeed in a majority 
of instances, its success is due not so much to the superior character of the 
food as to the infant's ability to adapt itself to its new food. This power 
of adapting to environment is feeble in these infants of unstable constitu- 
tion, and too much dependence should not be placed upon it. Valuable time 
and strength should not be wasted in attempts at finding a food that will 
agree with the infant when it is possible to secure a wet-nurse. 

A Wet-nurse Unobtainable. — When the services of a suitable wet- 
nurse cannot be had, substitute feeding must be tried, and methods that at 
one time would have been looked upon as quite unscientific are the ones 
most likely to give good results. One should not approach these cases with 
fixed ideas of what they ought to take and keep on with food that is evidently 
disagreeing. All of the infants must have protein, mineral matter, fats, 
carbohydrates, and water, and in this class of cases it is perfectly justifiable 
to supply them in any form that is acceptable to the infant. Of course, this 
statement is not to be construed as meaning any nostrum that may be sug- 
gested should be tried, but a combination of the food elements that is quite 
unlike either human milk or cow's milk in general composition or physical 
properties, such as given on page 144, may be offered. The point to bear in 
mind in the management of these cases is to keep the infants alive and as 
rapidly as possible build up their strength, and when this is done place 
them on a more natural diet. 

There is more to feeding than combining food elements in certain more 
or less definite proportions. A subtle factor in managing these difficult 
cases is the arousing of the dormant powers of digestion and assimilation 
of the infants. This is often accomplished by a change in the flavor, taste, 
or physical condition of the food and in the form in which some of the 
elements are supplied. (See catalysers, p. 143.) So simple a change as 
substituting dextrinized gruel for plain gruel of the same strength, in a 
modified milk mixture, has sometimes had a good effect. The use of cooked 
foods, meat-broths, or other forms of food, such as egg mixtures or legume 



PRACTICAL FEEDING. 143 

gruels, has also brought about sudden and permanent improvement. Chem- 
ical analysis does not show what there is about the food that produces such 
changes in digestion and assimilation, but that different forms of food do 
have different effects on different individuals is an undeniable fact, well 
known to animal feeders, who find that by catering to the idiosyncrasies of 
individual animals, much better assimilation is brought about, and more 
economical use is made of the food. This comes under the head, or in the 
same class, as the fact that food served to an adult in an attractive, appetiz- 
ing manner will be digested much better than if it is served in an un- 
attractive, repulsive condition. 

Catalysers. 

That a mere change in the flavor or form of food oftentimes produces a 
remarkable improvement in the assimilation of nourishment has long been 
known to investigators in the field of animal nutrition, as well as to many 
physicians, and the most striking results in difficult infant-feeding cases 
have come from the application of this principle although this fact has not 
always been recognized. 

Until recently, however, there has been no satisfactory explanation of 
this phenomenon, but experiments made to discover simpler processes of 
manufacturing certain chemical products, which could only be obtained by 
indirect methods, have brought to light a factor in chemistry whose im- 
portance hitherto had not been suspected, and which explains this peculiar 
effect on assimilation of a change in the form and flavor of foods. 

An illustration from actual experience will make the matter clear. It 
has long been known that certain chemical products can not be produced by 
merely bringing together their constituents in proper proportions. A mix- 
ture having the same chemical composition as the desired product can be 
obtained but no chemical combination is produced. However, the presence 
of some extraneous substance may cause the chemical combination to take 
place, although this substance does not enter into the combination ; remains 
unchanged, and can be used repeatedly for this purpose. 

Such substances are known as catalysers and a quantity so small as to 
be not detectable by chemical analysis is oftentimes all that is needed to 
cause certain chemical combinations to take place that would not occur in 
their absence. Xow, these catalysers may become poisoned and lose their 
efficiency, and then either a new supply of the same catalysers must be had 
or a different one must be employed, for different substances may have the 
power to cause the same chemical combination to take place. 

After foods have been digested they must be absorbed and then com- 
bined chemicallv to form the tissues. The materials necessarv to form the 



144 DISEASES OF CHILDREN. 

tissues are well known, but how to make them combine is not known. 
There are undoubtedly catalysers in the organism which cause the chemical 
combinations to take place and malnutrition is probably the result of their 
absence or of their being poisoned. A change in the character of the food 
may stimulate their production or present forms of food that they can 
cause to combine. The remarkable results obtained in industrial chemistry 
with catalysers in producing substances which have heretofore been obtain- 
able only by the action of living substances, seems to indicate that catalysts 
play a great part in nutrition. 

Food for the Acutely 111. 

Classification of Cases. — Under the heading of Acutely 111 it is 
intended to group only those whose illness is reflected in disturbances of 
the digestive organs or by general malnutrition. Infants may be acutely 
ill with pneumonia or other infections and still not show special derange- 
ment of the nutritional functions. Again, as in gastroenteritis, there is an 
infection or intoxication which calls for more than dietetic treatment, so 
such cases will be treated under their respective titles. 

Management of Cases. — In all of these cases it is of first import- 
ance to find something that will be retained, and before time is wasted 
in calculating a theoretically indicated mixture which may be rejected, it 
will be best to try some of the following mixtures, which if retained, will 
serve as a starting-point in working up to a suitable food mixture. 

1. Dextrinized barley, legume, oat or wheat gruel made with one 
ounce of flour to the quart, as directed on page 136. If any one of these 
gruels agrees, the strength may be increased to two ounces of flour to the 
quart. Such gruels will contain about 0.80 per cent, protein and 5 per 
cent, carbohydrates, except the legume gruel, which will contain about 1.5 
per cent, proteins with about 5 per cent, carbohydrates. 

2. Whey, made as directed on page 141, may be tried, which will 
contain about the same quantities of protein and carbohydrates as the gruels 
made with two ounces of flour to the quart. 

3. The white of one egg beaten up in eight ounces of water ma[y 
be retained when nothing else is tolerated. Such a mixture contains about 
1.5 per cent, of protein, but no carbohydrates or fat. Its nutritive value is 
not great. 

4. White of egg and dextrinized gruel, made by beating up the 
white of one egg with eight ounces of dextrinized wheat flour gruel ( 1 ounce 
to quart) will sometimes agre'e. If it is acceptable, one to two even tea- 
spoonfuls of granulated sugar may be added to the eight-ounce mixture, 



PRACTICAL FEEDING. 145 

which will then have about the following composition: protein 2 per cent, 
and carbohydrates 6 per cent. 

5. Yolk of egg and dextrinized gruel, made by adding the yolk of 
one fresh egg to eight ounces of dextrinized wheat flour gruel ( 1 ounce to 
quart), and if tolerated adding one to two level teaspoonfuls of granulated 
sugar, is highly nutritious and especially rich in blood making substances. 
If well borne in malnutrition cases legume flour may be used in place of the 
wheat flour. This will increase the quantity of nucleoproteids in the food 
materially. 

6. Meat broths oftentimes arouse the appetite, and if acceptable may 
be mixed with dextrinized gruels made with two to three ounces of flour to 
the quart, in equal parts, or they may be thickened with the gruel flours by 
stirring in an ounce of flour to the quart of broth and boiling. This will 
make a thick broth. 

To make broths, take one pound of lean mutton, veal, or chicken with 
some cracked bone and cut into small squares ; add one pint of cold water, 
heat gently, and allow to simmer for about three hours. Strain and add 
enough boiled water to make a pint of broth. When cool remove the fat or 
skim it off while hot. The broth will be gelatinous when cold and should 
be served warm. 

7. Beef tea is often useful as a digestive stimulant and is made by 
taking a pound of lean beef and cutting it into small pieces and allowing it 
to stand in a pint of cold water for an hour. It is then heated to not above 
160° F., and the meat is expressed through cheese cloth. If heated to above 
this temperature the albumin of the meat will coagulate. If the coagulum is 
allowed to remain in the tea none of the nutritive value will be lost, but if 
it is removed the tea will have little but flavor. 

8. Beef juice is often a useful addition to other foods in cases of mal- 
nutrition, and may be made as follow? : 

a. Slightly broil a thick piece of round steak that is perfectly free 
from taint. Cut into small pieces and press in a clean meat press 
or lemon squeezer. 

b. Cut the fresh steak into small pieces and just cover with cold, 
slightly salted water, and set on ice for several hours. Then press 
by squeezing in a piece of cheese-cloth. 

The quantity of beef juice given should not be over one ounce in twenty- 
four hours, and it is given to best advantage when added a teaspoonful at 
a time to other feedings, as in larger quantities the infant soon tires of it. 

9. Eiweissmilch. One quart of whole milk is heated to 100° F. for 
three minutes and then cooled to body temperature. Add 3 teaspoonfuls of 

10 



146 DISEASES OE CHILDREN. 

essence of pepsin to coagulate all of the casein. Break up the curd with a 
fork or spoon and allow to settle. The precipitated casein is allowed to 
settle and the liquid part is decanted. Straining the curd through linen or a 
wire strainer is impossible because the curd is of such consistency that the 
meshes of the strainer are quickly obliterated so that no drainage takes place. 
After all of the liquid has been removed and only the curd remains this pre- 
cipitate may then be put into a wire strainer and the remaining portion of the 
whey allowed to drain off. This dry curd is then pushed through a fine wire 
strainer by means of a spoon, into one pint of buttermilk and one pint of 
water. After the curd is strained into an empty dish, the particles quickly 
adhere and you have gained practically nothing by straining. This precipi- 
tate must be strained into liquid in order to make use of the colloidal action 
so that these particles will remain separated. The buttermilk, water and 
curd is then strained again, put into glass jars or bottles and kept on the 
ice. (Hunt.) 

10. Buttermilk. A pure culture of lactic acid bacilli is added to 
skimmed milk in an earthenware dish, and allowed to stand at about 70° F. 
for twenty-four hours, or until the casein is coagulated. Stir vigorously with 
a spoon or egg beater until the curd is very small, and then push the contents 
through a fine wire strainer with a spoon. If the buttermilk is too thick add 
a small amount of water. When the buttermilk is once made, a small portion 
(about four ounces) may be used as the inoculating agent for the next supply 
to be made. In this way the original culture may be made to last from six 
to eight weeks. The quality and action of product made will vary but 
little. Add the four ounces of buttermilk to the fresh milk, incubate and 
follow the above outline. Sometimes the milk will not coagulate al- 
though it may smell sour. Stirring gently with a spoon will often produce 
coagulation in a few minutes. The fat present will rise to the top and 
when coagulated appears as a brownish yellow scum which may be removed 
before the curd is broken up. (Hunt.) 

If any of the mixtures just given agrees, attempts at adding fresh cow's 
milk, a teaspoonful at a time, may be made. If the milk is tolerated the 
quantity may be increased cautiously until it forms one-fourth of the mix- 
ture, when the fats may be increased and the infant can be put on a 
formula suitable for its age as indicated on page 134. 

When all Attempts at Adding Fresh Milk Fail. 

When infants fail to thrive on any of the foregoing mixtures and all 
attempts at giving fresh milk in any quantity fail, the following mixtures 
may be tried and often are highly successful. Whenever the foods that are 



PRACTICAL FEEDING. 147 

cooked are used, a teaspoonful or two of beef juice or orange juice should be 
given daily, as on such foods infants are liable to develop scurvy. 

Formula No. 1. 

Whole milk 12 ounces. 

Wheat or oat gruel flour 4 level tablespoonfuls. 

Granulated sugar 2 level tablespoonfuls. 

Salt 1 pinch. 

Cold water 22 ounces. 

Mix cold and with constant stirring slowly bring to a boil and boil for three 
minutes. Strain and add enough boiled water to make thirty-two ounces. Feed 
quantity appropriate for age. For young infants or very delicate ones the food 
may be diluted with one part of water to two parts of the food. 

Approximate Composition. — Fat, 1.5 per cent.; carbohydrates (starch, milk- 
sugar, cane-sugar), 7 per cent.; protein, 1.5 per cent. 

By using the top 16 ounces from one quart of milk and taking 12 ounces of 
this instead of whole milk in the above mixture the percentages will be : Fat, 2.5 
per cent. ; carbohydrates, 7 per cent. ; and protein, 1.5 per cent. 

Formula No. 2. 

Whole milk 12 ounces. 

Wheat or oat gruel flour 4 level tablespoonfuls. 

Glycerite of diastase (Cereo) 3 teaspoonfuls. 

Salt 1 pinch. 

Cold water 22 ounces. 

Mix cold and with constant stirring bring slowly to a boil, and boil for five 
minutes. Strain and add enough boiled water to make 32 ounces. Feed quantity 
appropriate for age, or dilute two parts of the food with one part of water for 
very young or delicate infants. 

Approximate Composition. — Fat, 1.5 per cent.; carbohydrates (soluble 
starch, dextrin, maltose, milk-sugar), 6 per cent; proteins, 1.8 per cent. 

If top 16 ounce milk is used instead of whole milk, the percentage of fat will 
be 2.5 per cent. 

With both of the formulas above it will be better to begin with whole 
milk and increase to top sixteen ounce milk if digestion is good. 

Keller's malt soup is a mixture similar to the above. The carbohydrates 
in the mixture are starch, maltose, and milk-sugar. It is prepared as 
follows : 

Wheat flour 2 ounces. 

Whole Milk 11 ounces. 

Mix and rub through a fine strainer thoroughly. In another vessel add to 
20 ounces of water, and 3 ounces of malt extract (Keller uses Liebig's), warm to 
120° F. and add 1\ drachms of a 11 per cent, solution of bicarbonate of potash. 
Now boil these together. The approximate composition will be: Fat, 1.2 per 
cent. ; proteins, 2.0 per cent., and carbohydrates. 12.1 per cent. 

A few cases may be met in which no food previously suggested agrees. 
In these cases condensed milk, peptonized milk, or buttermilk may solve 
the problem. 

Condensed Milk Mixtures. — Fresh condensed milk is to be preferred, 
but if unobtainable the best brands of sweetened condensed milk should be 
employed. A teaspoonful of condensed milk to four ounces of plain or 
dextrinized gruel may be used at the start. If this is well borne, the quan- 



148 DISEASES OE CHILDREN. 

tity of condensed milk should be rapidly increased until two to four tea- 
spoonfuls to four ounces of diluent are used. Then equal parts of top milk 
and condensed milk should be mixed and used for dilution, which may be 
reduced until one part of this mixture is used with five parts of diluent. 

Peptonized Milk. Warm Process. — (1) Empty into a clean quart 
bottle the contents of one of Fairchild's peptonizing tubes; (2) add four 
ounces (eight tablespoonf uls ) of cold water; shake, and (3) add one pint of 
cool fresh milk and again shake; (4) place the bottle in water not too hot 
to be uncomfortable to the hand for ten minutes. Then either place on ice 
or boil to prevent further digestive action. This milk is likely to taste bitter. 

Cold Process. — Prepare the bottle as before, but set on ice without 
warming. This milk is only partially peptonized so will not have a bitter 
taste. 

Buttermilk. — For temporary use buttermilk has a limited field. It is 
best made at home by using a pure lactic acid ferment. Natural buttermilk 
contains little fat, as this has been removed as butter. In making buttermilk 
the cream may be removed and the ferment added to the skimmed milk, 
or whole milk may be used (see 10, p. 146). 

Two types of buttermilk food are employed. First, the raw butter- 
milk, which contains enormous numbers of lactic bacteria; second, butter- 
milk to which one ounce of flour (four level tablespoonf uls) is added to 
the quart, and boiled. Raw buttermilk introduces harmless bacteria into 
the digestive tract which may kill off those present that are harmful. 
Cooked buttermilk supplies a fairly sterile acidified food in which the casein 
is finely divided and cannot form a solid mass in the stomach. 

Laboratory Feeding. — In many of the larger cities are to be found 
the Walker-Gordon laboratories at which food for infants is prepared upon 
prescription of the physician.. They were established as the results of 
Eotch's teachings. Prescription blanks are furnished for those who wish 
to write out specific formulae. 

Calorie Feeding. — An attempt has been made to establish a calori- 
metric standard for use in feeding infants. A Calorie is a measure of heat, 
being the amount of heat required to raise the temperature of one liter of 
water one degree Centigrade. Heat, as is well known, is produced by 
chemical action, friction, mechanical movements, and in the utilization of 
food by the animal organism. 

It has been determined by experiment just how much heat is produced 
by the oxidation of practically all food substances and the burning of 
different kinds of fuel. 



PRACTICAL FEEDING. 



149 



Fats, sugars, starches, meats, and other forms of protein will all. produce 
heat, and all are digestible. If the heat or caloric value was all infants or 
adults needed food for, it would be immaterial what article of diet was. 
employed. But foods that are of equal heat producing value, and which 
are also digestible, are not interchangeable for different individuals, and 
growth and tissue repair do not depend upon the storage of heat, but upon 
the assimilation of protein. In infant feeding, particularly, where growth 
or the storage of protein is the chief phenomenon of nutrition, the main 
point to be considered is not, will the food supply heat, but, is it capable of 
causing growth? 

Table of Caloric Food Values. 

1 oz. Protein yields 123 calories. 

1 oz. Carbohydrates " 123 " 

1 oz. Fat " 288 

Key to Caloric Values of Percentage Mixtures. 

1 oz. Food containing 1% Protein yields 1 .23 calories. 

1 oz. " " 1% Carbohydrates " 1.23 

1 oz. " " 1% Fat " 2 . 88 

Example of Use of Key. 

What is the caloric value of 32 oz. of breast milk whose composition 
is protein 2 per cent., carbohydrates 7 per cent., fat 4 per cent.? 
32 oz. x 2% Protein x 1.23 cal. = 78.72 cal. from Protein. 

32 oz. x 7% Carbohydrates x 1.23 " =275.52 " " Carbohydrates. 
32 oz. x 4% Fat x2.88 " =358.4 " " Fat. 



712.64 cal. 



For roughly comparing the heat values of mixed diets, which prove to 
be suitable for the particular case from the digestive standpoint. 



Approximate Composition and Caloric Value of Foods Used 


in Infant 


Feeding. 




Water, 
per cent. 


Protein, 
per cent. 


Fat, 
per cent. 


Carbo- 
hydrates, 
per cent. 


Calories 
to 1 oz. 


Human milk 


87.0 

89.0 

87.0 
86.5 
74.0 
77.0 
80.0 
83.5 
84.8 
90.5 
91.0 
89.3 
26.9 
68.2 
93.0 

12.0 
11.4 
9.4 
7.0 
7.3 
6.5 
5.0 
9.5 


2.0 

3.0 
3.3 
3.5 
2.5 
2.5 
3.0 
3.2 
3,2 
3.4 
3.0 
2.8 
8.8 
9.6 
1.0 

11.4 
13.8 

7.4 
14.0 
16.0 
25.0 
44.0 

7.9 


4.0 

3.0 

4.0 

5.5 

18.5 

16.0 

12.0 

10.0 

7.0 

0.3 

0.5 

2.1 

8.3 

9.3 

0.3 

1.0 
1.9 

7."2 

19.0 
0.4 


7.0 

5.0 
5.0 
5.0 
4.5 
4.5 
5.0 
5.0 
5.0 
5.1 
4.8 
5.4 
54.1 
11.2 
5.0 

75.1 
71.9 
SI. 5 

77.0 
67.8 
67.0 
10.9 
81.9 


99 


Cow's milk: 

Ordinary milk 


18.5 


Good milk 


21.0 


Jersey milk 


26.0 


Cream 


62.0 


Top milk 16% fat 


55 . 


Top milk 12% fat 


44.0 


Top milk 10% fat 


39.0 


Top milk 7% fat 


30.0 


Skim milk 


11.0 


Buttermilk 


10.0 


Koumvss 


15.0 


Condensed milk (sweetenedY. . 


95.0 


Evaporated milk 


48.0 


Whev. 


8.0 


Cereals for Gruels: 

Wheat flour 


104 


Entire wheat flour 


105 




109 


Cereo Co.'s barley 


110 


Cereo Co.'s oat flour 


120 


Cereo Co.'s legume flour 


113 




120 


Rice, flaked 


105 



150 DISEASES OF CHILDREN. 

When the composition and weights of the foods eaten are known, and 
also to act as a sort of check, the caloric values of the foods may serve a 
useful purpose, and to enable those who wish to become familiar with 
caloric food values the preceding key and table are given. 

Heubner gives the following caloric requirements for infancy : 

First three months, 100 calories per kilo of body weight ; second three months, 
90 calories per kilo of body weight ; after that, until the end of the first year, 80 
calories per kilo. 

Langstein-Meyer gives the following caloric needs : 

1- 2 weeks, 107 calories per kilo of body weight. 

13-14 " 91 4i '• " " " " 

25-36 " 83 " " " " 

37-44 " 69 " " " " 

The usual percentage system as applied in this country gives a very 
close approximation of the caloric needs as they have thus been worked out. 
A kilo represents 2.2 lbs. 

Finkelstein's Classification. 

The nutritional troubles of the breast and artificially fed infants this 
author divides into: 

(1) Those due to weight disturbances, in which, in spite of seemingly 
adequate formulae, the weight goes up and down, and who become worse if 
the fat content is increased. Their stools are soapy, dry and light-colored. 
The condition is relieved by cutting down the high fats to whole or 
skimmed milk and giving malt sugar preparations up to eight per cent. 

(2) Dyspepsia follows aggravation of the symptoms enumerated under 
(1). The weight now remains stationary or declines; there is an irregu- 
lar temperature, with stools showing intestinal fermentation and a tendency 
to diarrhea. Breast milk should be furnished or skimmed milk without 
any sugar, or with Keller's malt soup, is to be given. 

(3) Atrophy or decomposition follows a fat and salt intolerance with 
rapid loss of weight. There is a starvation cry and beefy tongue. The 
temperature is apt to be subnormal and stools foul and undigested. 
Anasarca and cyanosis may precede death. 

Here breast milk is imperative, and even this may have to be diluted 
or skimmed. 

(4) Intoxication (compares with our exogenous infective diarrheas) 
and may complicate any of the above or arise de novo. There is a marked 
sugar intolerance, but protein digestion is unimpaired. The fever is inter- 
mittent with toxic symptoms. The stools are watery and frequent. The 
urine contains some albumin and casts and sometimes lactose or galactose ; 



PRACTICAL FEEDING. 151 

weight is lost rapidly and somnolence or stupor supervene. The condition 
is combatted by withdrawal to a cooler atmosphere, stopping all sugar, and 
feeding with Eiweiss milk (see p. 145). Sugar only is added when the 
symptoms subside. 

Directions for the Mother or Nurse. 

Education of Mother Necessary. — One of the greatest aids in the 
feeding of infants artificially is intelligent cooperation of the mother, and 
it should be explained to her that as she would naturally feed the infant 
until its digestive organs are sufficiently developed to digest soft table food, 
it is her duty to become acquainted with the details of preparing and admin- 
istering artificial food. Time expended in teaching a mother how to pre- 
pare food and why the different processes are used will be well spent, and 
will eventually repay the physician. 

The mother or nurse should be shown just what she is expected to do. 
Directions should be written out. The feeding schedule on page 134 may 
be followed as a general guide as to what the formulas for different ages 
should be and the pictorial directions (page 135) when shown to a mother 
will make things clearer than long explanations. 

Care of Food. — "When a good, clean milk cannot be obtained, or when 
the conditions are such that the food, after being prepared, cannot be kept 
below 50° F., it should be pasteurized. The fact that the food is kept in a 
refrigerator does not necessarily mean that it is kept cool, as the tempera- 
ture in some refrigerators is above 60° F. The food should be kept sur- 
rounded by ice. 

Xursing bottles of the style shown in Fig. 45 should be used, as they 
can he readily cleaned. After the food is placed in them they should be 
stoppered with clean absorbent cotton. Corks should not be used, as the 
milk gets into the pores and sours, or otherwise spoils and infects the next 
feeding. 

If the food is to be pasteurized the Freeman pasteurizer (Fig. 46) may 
be used, or when this is not available a home-made pasteurizer may be 
employed (Figs. 47, 48). This is made from a six-quart tin pail. A false 
bottom is made by punching holes in a tin pie plate which is then inverted 
in the pail. The bottles of food or milk are placed on the false bottom, 
and water is poured around them up to the level of the milk. The pail is 
then placed on a stove and the water brought to a temperature of 105° F.. 
as determined by a thermometer. The pail is now covered with a cloth 
and remover] from the stove, and allowed to stand for half an hour. A 
folded newspaper is a good thing to stand the pail on. as it will prevent too 



152 



DISEASES OF CHILDREN. 



rapid loss of heat. After standing half an hour the food or milk should be 
cooled by placing it in cold water, until thoroughly cooled, otherwise the 
bacterial spores which are not destroyed by pasteurizing will germinate and 





Fig. 45. — Nurs- 
ing bottle, prefer- 
able type. Fig. 46.— Freeman pasteurizer. 

may cause disturbance of the infant's digestive tract. Old pasteurized milk 
should never be used. Fresh food should be made every day. 

Administration of Food. — Eegularity in feeding should be insisted 
upon. The food should be slightly warmed by placing the bottle in warm 



^v 




A A 



w 



A 



4 



Fig. 47. — Home-made 
pasteurizer. (Russell.) 




Pasteurizer for bottled milk. 
(Russell.) 



water for a few minutes. Night feedings should not be warmed before 
retiring and kept warm. This is a pernicious practice. The cotton stopper 
is then removed and a black rubber nipple should be placed on the bottle, 



PRACTICAL FEEDING. 



153 



which should be inverted to see that the hole in the nipple is large enough 
to allow the food to drop slowly, but not so large as to permit the food to 
run in a stream. The mother or nurse should be cautioned not to put the 
nipple in her mouth. By allowing the food to drop on the wrist it will be 
possible to determine whether it is too hot or too cold. 

The infant should not be over twenty minutes in taking its food, and 
if satisfied will drop off to sleep. Never use the food that may be left in 
the bottle, but throw it away. If a considerable portion of the food is left 
in the bottle the nipple should be examined to see if the 
hole is too small or has become clogged. 

Care of Utensils. — After preparing food the dipper, 
double boiler, bottles, spoons, and all articles that have 
been used should be washed, first with cold water, and 
then with soap or washing compound and hot water, and 
then scalded. The bottles should be cleaned with a 
brush (Fig. 49), and after being scalded should be kept 
inverted until ready to be filled again. The nipples 
should be thoroughly washed and kept lying in a cup 
of water in which a good-sized pinch of borax has been 
dissolved. 

Examination of Stools. — The mother should be 
taught to examine the stools and to report to the physi- 
sian the appearance of anything abnormal, as change of 
color, diarrhea, the appearance of curds or of mucus. 
The mother should not be taught that these are alarming 
symptoms, but that they indicate something is wrong and needs attention. 




Fig. 49.— 
Bottle brush. 



How to Interpret Results. 

Weighing the Infant Important. — Infants should be weighed at 
regular intervals in about the same clothing, as steady gain in weight is 
one of the indications that they are thriving on their food. But judging 
the value of a food by the mere fact that it causes gain in weight is quite 
wrong, as the gain may be only in fat. 

The composition of the food, the general development and gain in 
weight should be taken into consideration, and no infant should be dismissed 
until its food contains considerably over one per cent, of protein and it is 
gaining in weight on it. 

The gain in weight is greatest in proportion during the first few 
months, as food is assimilated more completely at this period, as has been 
explained on page 125. Just how much an infant should gain each week 



154 DISEASES OF CHILDREN". 

cannot be stated definitely, as infants vary in this respect. Some will gain 
a pound and others not over two ounces, but the latter gain is too small 
for a healthy infant. Six ounces is a good gain. If the food is agreeing 
the quantity or strength may be increased cautiously to see if greater gain 
will result, but this plan must not be pushed to an extreme, for loss instead 
of gain may result. A record of the weight should be kept. Weight charts 
have been prepared on which is shown the " normal weight curve " deduced 
from the average gains of a large number of infants. It is better not to use 
this style of weight chart, as few infants pass their first year without some 
ups and downs, and the slightest variation from the " normal curve " is a 
cause of worry and anxiety to the mother and through her to the physician. 

Feeding in Hot Weather. — Upon the advent of hot weather special 
precautions should be taken to forestall attacks of gastroenteritis. The 
means for keeping the food cool should be looked after, and tested with a 
self-registering thermometer, or the food should be kept packed in ice to 
make sure it is kept cool. Pasteurization is a safeguard, particularly if ice 
is not available. If the infant has a tendency to indigestion or to vomit- 
ing, the amount of fat in the food should be reduced. One or two feedings 
of gruel used as the diluent may be put up, and given as night feedings or 
as substitutes when milk feedings seem to disagree. 

If the air is humid and the temperature high, the infant should be 
given a sponge bath twice a day. The excess of body heat is excreted by 
the evaporation of perspiration, and this is retarded by high humidity. 
And unless the skin is kept clean and free from the residue from the evapo- 
ration of perspiration, this will also retard evaporation. 

Feeding when Traveling. — Changes in the food are risky at any 
time, and especially so when traveling. A good plan to follow is to have 
the regular food prepared and packed in ice to insure thorough cooling 
and then to place it in vacuum bottles. The bottles should be filled right 
up to the stopper, otherwise the agitation of the food will churn the milk 
so that the fat will separate as butter. Several of these bottles will be 
required if the journey is to last several days. If there is a question about 
the food being kept cool, it should be pasteurized, then cooled or iced if 
possible, before being put into the vacuum bottle. These bottles will keep 
food cold for about seventy-two hours. 

The food for the infant can be poured from the vacuum bottle into a 
clean nursing bottle and warmed as wanted. But the food should be slightly 
shaken so as to mix the cream which will have risen to the top with the 
remaining milk. The food should not be warmed and then kept in one 
of these bottles to save warming. Milk soon spoils if kept warm. 



PRACTICAL FEEDING. 155 

For a single day's journey the food may be put up as usual in the home 
and boiled and put in a pail with cracked ice around the bottles. 

When it is not possible to have the foregoing directions carried out, 
one of the best brands of sweetened condensed milk diluted with boiled 
water may be used. The boiled water may be carried if it will not be 
obtainable during the journey. 

Feeding when Away from Home. — During the heated term large 
numbers of families leave the cities and live in the country at boarding 
houses, hotels, or in their own homes. In many of the more remote dis- 
tricts the milk-supply problem has not yet been solved, .and much disturb- 
ance may be caused by milk which has been improperly handled through 
ignorance. 

In such instances the mother should make an arrangement with some 
milkman or farmer to supply milk produced under sanitary conditions. 
The farmer should be instructed to clean the cows as thoroughly as he cleans 
his horses, to wipe the belly and udder with a damp cloth before milking, to 
wash his hands before milking, and to reject the first two or three jets from 
each teat. The milk pail should be well washed and scalded after being 
used, and kept inverted in the sun. As soon as the milking is finished the 
milk should be mixed, as it is not uniform in composition as it leaves the 
cow. and then poured into quart milk bottles. These should be set in ice- 
water, or if this is not obtainable, into cold well water which rises nearly to 
the tops of the bottles. The milk can be delivered in the morning in time 
to prepare the food for the day. 

Such milk will cost more than the ordinary milk, but it is worth all 
it costs, and will be found cheaper in the end. The mother should see for 
herself that the milk is produced under cleanly conditions. She would not 
tolerate a filthy wet-nurse for her infant and should not allow her infant's 
food to come from a filthy cow. 

Feeding Among the Poor. — The preparation of food or even obtain- 
ing suitable food materials is often a perplexing problem among the poor 
and in the tenements of large cities. The intelligence of the mother may 
be limited, and even when the mother is capable of carrying out directions 
the facilities for preparing food and keeping it cool are wanting. Some 
families are too poor to buy clean bottled milk at ten cents a quart, and 
oftentimes such milk is not offered for sale in the poorer sections of a 
community. 

Correct dietetic principles must be applied as best they can be. Where 
good milk can be obtained, but careful modification cannot be expected, the 
food may be made with whole milk and gruel, using one-fourth, one-third, 



156 DISEASES OF CHILDREN. 

and one-half milk and adding one part of granulated sugar to thirty- three 
parts of food, or two level tablespoonf uls to the quart of food. 

Where good milk is unobtainable, condensed milk may be used with 
water or barley gruel made with one ounce of flour to the quart. The milk 
should be diluted 8 to 15 times, that is, one part of condensed milk to 7 to 
14 parts of water or gruel. Xo sugar is to be added. Cod-liver oil or olive 
oil can be given daily, one teaspoonful three times a day, to supply the fats. 

Infant's Food Dispensaries. — The unsatisfactory results obtained in 
infant-feeding among the tenement population, owing to improper prepara- 
tion of food or lack of suitable food, has led to the establishment of food 
dispensaries in the crowded sections of many cities. There are three types 
of these feeding stations: (1) Those at which a few formulas of modified 
milk may be obtained in nursing bottles by anyone who applies for them. 
(2) Those at which modifications of milk are given by trained physicians 
who examine the applicants and aim to give a formula which is likely to 
agree. (3) Those at which the food is prepared for each infant while it 
waits, upon the prescription of the attending physician. 

The feeding stations at which food is dealt out without taking into 
consideration the condition of the infant are not to be encouraged, for while 
they do much good, they also do harm. 

During the heated term feedings of plain and dextrinized gruels made 
with one to two ounces of barley flour to the quart should be kept on hand 
to be given when milk feedings disagree ; for infants that are quite sick 
they may be diluted once with boiled water. 



CHAPTER XVI. 



DIET DURING THE SECOND YEAR. 



By the beginning of the second year the infant's digestive organs 
should be sufficiently developed to warrant giving some soft food. 
The greatest amount of trouble will be caused by cereals which are 

not properly cooked. Fig. 50 shows a cross- 
section of an oat grain. It will be observed 
that the protein and carbohydrates are in- 
closed in cells. These are composed of cellu- 
lose which is indigestible, and they must be 
ruptured by cooking before the digestive 
secretions can get at their contents. Fig. 51 
shows what takes place when cereals and 
vegetables are cooked properly and too much 
emphasis cannot be laid upon the importance 
of thoroughly cooking cereals. Oatmeal par- 
ticularly should be cooked in a double boiler 
several hours. Flours do not need such long 
cooking. 
The following schedule has been arranged as a suggestive scheme for 
the feeding of older normal children: 




Fig. 50. — Section of oat 
grain, <?. protein layer; d, 
starch and protein. (Good- 
ale.) 




Fig. 51. — Rupture of starch grains by cooking. (Langworthy. 



Many children are indiscriminately fed, and the physician being 
unfamiliar with the kind of food suitable and agreeable to the child neglects 
to supply directions as to the dietary. Changes should be made in the list 

157 



158 DISEASES OF CHILDREN. 

if there is illness, habitual constipation, or difficulty in digesting certain 
forms of food. It should be recollected that the child can be trained to like 
almost every suitable article, and it is a mistake to cater to their likes and 
dislikes if they are not developing and gaining weight. 

Under their respective sections changes in the character of the food 
have been suggested where they have any bearing on the progress of the 
disease. 

Dietary. 
Twelfth to Eighteenth Month. — Select from the following articles: 
First meal — on arising. 

Juice of a sweet orange, one to two ounces. 
Pulp of six stewed prunes. 
Pineapple juice, one ounce. 

Milk, eight ounces, zwieback, toasted biscuits (as Huntley & 
Palmer's), stale toasted bread. 

Second meal — during forenoon. 
Milk alone or with zwieback. 

Noon meal. 

Soup made of chicken, beef, or mutton, six ounces; or beef juice 
three ounces. Stale or toasted bread may be added to the above. 

Fourth meal — afternoon. 

Milk, or toasted bread and milk. 

Evening meal. 

Gruel made of oatmeal, farina or barley, taken with whole milk, 

four ounces of each. 
Apple sauce or prune jelly. 
Zwieback. 

Eighteenth to the Twenty-fourth Month. 

Breakfast. 

Juice of one sweet orange. 
Pulp of six stewed prunes. 
Pineapple juice, one ounce. 

A cereal, such as cream of wheat, oatmeal, farina, or hominy 
preparations with top milk (top 16 oz.). Sweetened or salted. 
A glass of milk. 



DIET DURING THE SECOND YEAR. 159 

Forenoon. 

A glass of milk with two toasted biscuits or zwieback. 

Dinner. 

Broth or soup made of beef, mutton, or chicken and thickened 
with peas, farina, sago or rice; or beef juice with stale bread 
crumbs; clear vegetable soup with yolk of one egg; or egg, 
soft boiled, with bread crumbs, or the egg poached, or a baked 
potato. 

A glass of milk. 

Dessert. — Apple sauce, prune pulp, stale lady-fingers, or graham 
wafers. 

Supper. 

Custard. Cup of milk warm or cold. Stewed fruit. Zwieback. 

Two to Three Years. 

Breakfast. 

Juice of one sweet orange; pulp of six stewed prunes. 

Pineapple juice, one ounce, or apple sauce. 

A cereal, such as oatmeal, farina, cream of wheat, hominy, or rice, 

slightly sweetened or salted as preferred, with the addition of 

top milk (top 16 oz.) ; or a soft-boiled or poached egg with 

stale bread or toast. 
(If there is a tendency to constipation give the fruits before 

breakfast with water; if not, they may be given during the 

forenoon if preferred.) 
A glass of milk. 

Dinner. 

Broth or soup made of chicken, mutton, or beef thickened with 

arrowroot, split peas, rice, or with the addition of the yolk of 

an egg or toast squares. 
Scraped beef, white meat of chicken, broiled fish (halibut is free 

from bones). 
Mashed or baked potato, fresh peas, spinach, asparagus tips. 
A glass of milk with educator crackers. Huntley & Palmer biscuits 

or graham wafers. 
Dessert. — Apple sauce, baked apple, rice, junket, or custard. 



160 DISEASES OF CHILDREN. 

Supper. 

Stewed fruit. 

A cereal or egg (if not taken for breakfast) ; bread and milk; 
or custard ; cup of warm milk or cocoa ; crackers or zwieback. 

Three to Six Years. 

Breakfast. 

Fruits. — Oranges, cantaloupe, apples, or stewed prunes. 

Cereal. — Oatmeal, hominy, rice and wheat preparations, well 

cooked and salted, as described on page 157, with thin cream 

and sugar. 
Eggs. — Soft boiled, poached. 
Milk. — Milk or cocoa to drink. 

Dinner. 

Soups. — Beef, chicken, or mutton, or milk soups. 

Meat. — Chicken, beefsteak or roast beef, lamb chops, fish. 

Vegetables. — Spinach, carrots, string beans, peas, cauliflower 

tops, mashed or baked potato, asparagus tips. 
Bread and butter (not fresh bread or rolls). 
Dessert. — Custard, rice or bread pudding, tapioca, ice cream 

(once a week), prune souffle, or baked apple. 
Milk. 

Supper. 

Milk toast, or a thick soup, as pea, or cream of celery, or a cereal 
and thin cream. Egg. Stewed fruit, custard or a plain pud- 
ding, graham crackers and milk. 

Suggestive Diet List Suitable for Children's Hospitals. 
Monday. 
Breakfast. — Oatmeal, bread and butter, milk. 
Dinner. — Beef soup, chicken, mashed potatoes, bread and butter, corn starch 

pudding, milk. 
Supper. — Bread and butter, milk, apple sauce. 

Tuesday. 
Breakfast. — Eggs, bread and butter, milk. 
Dinner. — Chicken soup, chicken, mashed potatoes, bread and butter, rice pudding, 

milk. 
Supper. — Bread and butter, milk, stewed prunes. 

Wednesday. 
Breakfast. — Hominy, bread and butter, milk. 
Dinner. — Beef soup, ronst beef, mashed potatoes, bread and butter, bread pudding, 

milk. 
Supper. — Bread and butter, jam, and milk. 



DIET DURING THE SECOND YEAR. 161 

Thursday. 

Breakfast. — Eggs, bread and butter, milk. 

Dinner. — Beef soup, chicken, masbed potatoes, bread and butter, ice cream, milk. 

Supper. — Bread and butter, jam, and milk. 

Friday. 

Breakfast. — Oatmeal, bread and butter, milk. 

Dinner. — Mutton brotb, roast mutton, masbed potatoes, bread and butter, cus- 
tard pudding, milk. 
Supper. — Bread and butter, milk, apple sauce. 

Saturday. 

Breakfast. — Hominy, bread and butter, milk. 

Dinner. — Beef soup, roast beef, masbed potatoes, bread and butter, chocolate 

pudding, milk. 
Supper. — Bread and butter, milk, stewed prunes. 

Sunday. 

Breakfast.— Oatmeal, bread and butter, milk. 

Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, ice cream. 

milk. 
Supper. — Bread and butter, milk, jelly. 

Suggestive Diet Lists for Day Nurseries and Creches. 
Group 1 (Bottle-weaned babies). 
Milk (whole milk), warm or cold, 8 ounces. 
Farina gruel with milk and sugar, zwieback. 
Beef or mutton soup, thickened with toast crumbs. 
Orange juice. 1 ounce. 
Apple sauce. 
Prune pulp. 

Amount needed daily — three meals — 24 ounces milk, 10 ounces soup, zwie- 
back, 2 pieces, fruit, one kind. 

Group 2 ("Runabouts"). 
Milk. 

Zwieback or toast, or stale bread. 
Soft-boiled egg. 

Farina, cream of wheat, oatmeal. 

Soup, beef or mutton thickened with split peas, rice, or farina. 
Baked potato, mashed potato, carrots, beets. 
Custard, cornstarch, farina pudding, apple sauce, prune jelly, or apple 

butter. 
Amount required daily, three meals. 36 ounces of milk, one cereal, one 

vegetable, one soup, bread, one fruit. 

Group 3 (Kindergartners — two meals). 

Bowl of crackers and milk, farina, oatmeal. 
Beef or mutton stew. 
Eggs, soft-boiled or scrambled. 
Mashed potato, peas, carrots, beets, cauliflower. 
Rice pudding, cornstarch pudding, baked apple, apple sauce, prunes. 
Amount required, three cups milk, soup, vegetable, bread and butter, 
cereal or pudding. 
11 



162 DISEASES OF CHILDREN. 

Group 4 (School age). 
Noon. 

Soup, beef or mutton. 

Beef or mutton stew. 

Potato (mashed), spinach, carrots, or beets. 

Bread and butter. 

Pudding, farina, rice, cornstarch. 
•4 P. M. 

Milk, cocoa. 

Bread and butter, jam. 

Raw apples. 

Diet During Later Childhood 

The period of growth from early childhood to puberty requires careful 
oversight of the nutrition. The child must be regularly trained in all the 
hygienic details of feeding, including slow eating and the avoidance of 
strenuous exercise just before or after eating. The diet requires a large 
amount of protein owing to the rapid growth, and this must be supplied 
principally by the ordinary meats (beef, mutton, and chicken) and such 
vegetables as peas and beans. All the cereals will also supply some protein 
with a large amount of starch. The heat- and energy-producing foods 
(starches, sugars, and fats) may be supplied in the form of potatoes, 
cereals, fruits, and fats from milk or meat. It is very desirable to train 
the child to take a varied and properly balanced diet, which includes all the 
foods in common use. Thus if very much meat is taken to the exclusion of 
carbohydrates, the protein will be employed too largely in oxidation to 
produce body heat instead of in building tissue, and hence growth may be 
retarded. A certain amount of the carbohydrates acts as protein sparers, 
and thus allows the protein to be used entirely in its proper function of 
building tissue. This is an example of the desirability of a properly bal- 
anced diet. The green and succulent vegetables and fruits also have an 
important function in nutrition, as is seen in cases of scorbutus where there 
has been a long deprivation of these articles of diet. Lesser degrees of 
malnutrition result if they are not taken in proper amount. 

The two usual cycles of growth, namely, at the second dentition and 
adolescence, require an especially generous diet. Rapid growth always uses 
up nutrient material and hence calls for food rich in protein, otherwise 
various grades of anemia are liable to result. 

Dietary Suitable for Children After the Sixth Year. 
Soups. — Beef broth, chicken broth, mutton broth, oyster broth, bouillon, 

milk soups, purees of vegetables, legumenose soups. 
Vegetables. — Peas, carrots, spinach, baked potato, mashed potato, stewed 

potato, celery, string beans, lima beans, beets, beet-tops, rhubarb, 

squash, pumpkin, lettuce, endive, stewed tomatoes. 



DIET DURING THE SECOND YEAR. 163 

Eggs. — Soft-boiled, poached eggs, scrambled eggs, omelet (plain). 

Sea Food. — Raw oysters, steamed oysters, boiled fish, broiled fish. 

Meats. — Beefsteak, roast beef, roast chicken, minced chicken, boiled 
chicken, broiled chicken, roast mutton, roast lamb, lamb chop, turkey, 
squab, sweetbreads. 

Farinaceous. — White bread, whole wheat bread, graham bread, corn cake 
(not hot), gems, toast, plain crackers, educators, zwieback, farina, 
cream of wheat, oatmeal, rice, hominy, macaroni (plain), spaghetti 
(plain). 

Fats. — Cream, butter, olive oil. peanut butter. 

Beverages. — Milk, topmilk, buttermilk, cocoa, matzoon. 

Dessert. — Stewed fruits, baked custard, bread pudding, cornstarch pud- 
cling, rice pudding, tapioca pudding, junket, plain cake, ice cream. 

Fruits. — Eaw apples, baked apples, apple sauce, stewed prunes, stewed figs, 
pears, peaches, grapes, oranges, grape-fruit, melons, strawberries, rasp- 
berries, blue berries, blackberries. 

Suggestive Diets for Special Conditions. 
Diet after ax Attack of Becurrext Vomitixg (for -i Years or Over). 
May have for the first two iveeks the following : 

Oatmeal, Petti John, farina, cream of wheat, rice, yellow corn meal, 

milk toast, graham bread (stale). 
Baked apple, apple sauce, stewed prunes, stewed figs. 
Purees of vegetables, as celery, spinach, carrots, peas, baked or mashed 

potato. 
White meat of chicken, sweetbreads. 

Junket, baked custard, cornstarch pudding, bread pudding, blanc 
mange, home-made ice cream (once a week), milk after removal of 
top 2 oz.. cocoa, buttermilk. 

May have after two weeks the following in addition: 

Steamed oysters, broiled fish, butter, spinach, peas, lettuce, rice pud- 
ding, mutton broth, chicken broth. 

Eggs. — Soft-boiled, coddled, dropped. 

Lamb chop, beefsteak, roast beef, chicken (roasted, minced, boiled or 
broiled). 

Beets, carrots. 

Stewed apples or stewed pears. 



164 diseases oe children. 

Diet to Overcome Constipation: Suitable for a Child 8 Years Old. 

Breed-fast. 

Juice of a sweet orange, or six stewed prunes, or baked apple, or stewed 
peaches. 

A cereal, as oatmeal, farina, rice, hominy or corn meal, with top milk 
or butter, as preferred, or a soft-boiled egg, or egg poached or cod- 
dled, with bran biscuits or muffins, or graham bread. 

A glass of milk. 

Dinner. 

Broth or soup made of chicken, beef or mutton, thickened with split 
peas, or rice with yolk of egg or toast squares. 

Puree of peas, carrots, or potato. 

Broiled lamb chops, beefsteak, chicken, roast lamb, saddle of mutton, 
roast beef, roast chicken, minced chicken, boiled chicken, broiled fish 
as halibut or sole. 

Carrots, beets, squash, cauliflower tops, mashed or baked potato, celery, 
peas, beet greens, spinach, string beans, young lima beans, plain 
macaroni, spaghetti, graham bread and butter, a glass of milk, gra- 
ham crackers, bran biscuits. 

Dessert. — Apple sauce, baked apple, plain rice pudding, bread pudding, 
tapioca pudding, junket, baked custard, ice cream (home made) 
twice a week. 

Supper. 

Stewed fruit and a cereal or egg (if egg is not taken at breakfast), 
custard or rice, warm milk or cocoa with graham crackers or graham 
bread, or bran biscuits. 

Eecipe for Bran Muffins. 

1 egg. 

1 pinch of salt. 

J cup of molasses. 
1J cups of milk. 

2 cups of bran. 
1 cup of flour. 

3 teaspoonful of soda. ... , a . . 
Beat egg and salt together, add molasses and milk ; mix in bran and flour last. 

Moisten the soda with a tablespoonful of warm water. Mix all together. Bake in 
moderate oven. (Do not get too stiff.) 

Diet after Diarrhea Attack in Older Children. 
Skimmed milk boiled, baked potato, white meat of chicken, macaroni, 
farina, hominy, rice, toast, arrowroot crackers, soft eggs, cold boiled 
water. 



DIET DURING THE SECOND YEAR. 165 

When stools become formed allow : 

Lamb chop, rare roast beef, strained apple sauce, carrots creamed, milk 
(remove top 2 ozs. of the cream and pasteurize). 
Then gradually resume regular diet. 

Diet List for Obesity. 

(Prepared for 10-year-old child.) 
Breakfast. 

1 orange, 3 pieces of toast or 4 pieces of bran bread, 1 butter ball, fish 
(except salmon or eels), 1 glass of milk (hot or cold). 

Dinner. 

One of the following soups : Bouillon, consomme, julienne, or any thin 
soup. 

1 tablespoons of white meat of chicken, or 2 ounces of rare roast beef, 
or 2 ounces of rare mutton ( very lean ) . 

Liberal helping of string beans, spinach, celery, kale, cauliflower, cab- 
bage, beans, asparagus, young onions, tomatoes, plain lettuce or with 
lemon juice, sour grapes (tart), orange. 

Supper. 

1 or 2 soft-boiled or poached eggs, 3 slices of bran bread, or 6 graham 

crackers. 
Drink very little water, cup of cambric tea, cut up oranges. 
Water taken preferably between meals if necessary. 

If very hungry upon retiring, may have a glass of skim milk and 5 graham 

crackers. 
To be judiciously increased as excessive weight is lost. 

Diet Preponderating in Carbohydrates. 

(Prepared for 5-year-old child.) 
Breakfast. 

Juice of a sweet orange, or six stewed prunes, or baked apple, or 4 ozs. 
of apple sauce: 4 ozs. of a cereal, as oatmeal, farina, rice, sago, hom- 
iny, corn meal with butter: stale bread and butter, wheat bread. 
graham bread, 2 pieces. 

Dinner. 

3 tablespoons of carrots, 1 medium size meshed or baked potato. 3 
tablespoons of beans, peas, sweet potato, beet greens, cauliflower. 



166 DISEASES OF CHILDREN. 

celery, squash, beets, graham bread or graham cracker, 2 pieces; 
macaroni or spaghetti, 3 tablespoonf uls ; stale bread and butter, 2 
slices. 
Desserts. — -Apple sauce, 4 ozs.; baked apple; plain rice pudding, 4 
ozs. ; tapioca pudding, 4 ozs.; cornstarch pudding, 4 oz., or arrow- 
root pudding, 4 ozs. 

Supper. 

Stewed fruit, 4 ozs.; a cereal, 4 ozs., or peas or green vegetables, 3 
tablespoons (whole wheat bread or graham bread if constipated). 

After the two weeks may be added the following: 
Whole orange, 1 egg, soft, coddled or shirred. 
Eacahout. — 1 tablespoon to 6 ozs. of water, once daily. 
Milk, 1 pint for entire day. 
Peanut butter, 2 teaspoons every other day. 

An elastic dietary slip such as the following, prepared by Dr. C. H. 
Smith, can be readily adjusted by the practitioner to suit the needs of the 
individual child : 

Diet List. 
Date Diet for 



Breakfast. At.. ........ . 

Fruit : Orange juice, or cooked apples, or stewed prunes, or stewed 
dry peaches. 

Cereal ( . . . . tablespoonfuls ; no sugar) : Oatmeal, wheatena, malt 
breakfast food, Petti John's, corn meal, cream of wheat, farina, hom- 
iny, rice. Cook two or three hours, night before, in double boiler. 

Milk: .... cups (put part on cereal), or weak cocoa. 

Toast, or zwieback, or bread, and butter. 

Egg, soft boiled, poached, or scrambled (without butter). 

Dinner. At 

Soup : Broth or any cream soup may be given, if not greasy, but there 

is not much food in soup. Do not make this the main part of the 

meal. 
Meat : One of these : 

Beef steak (broiled), chopped beef (cooked dry in pan with no 
grease nor butter). 

Roast beef. 



DIET DURING THE SECOND YEAR. 167 

Koast lamb, lamb chop (broiled or cooked in pan with no grease nor 

butter). 
Chicken, roast or broiled (no gravy). 
Fish, boiled cod or halibut. 
Vegetables : Give .... tablespoonfuls of each, green and white, every 
day. 
Green : Spinach, peas, stewed celery or knob celery, oyster plant, car- 
rots, string beans, lima beans, squash, beets, greens, turnips, aspar- 
agus tips, stewed tomatoes, cauliflower, parsnips. 
"White: Potatoes (boiled, baked, mashed, creamed), sweet potatoes 
(boiled or baked), rice, macaroni, hominy. 
Toast or stale bread. 

Dessert: .... tablespoonfuls of rice or bread pudding (no raisins), 
junket, custard, cornstarch, gelatine, ice cream or cooked fruit. 

Supper. At 

Cereal, .... tablespoonfuls ; milk, .... cups ; toast or stale bread. 

Or, bread, .... slices, and milk, .... cups, or milk toast. 

Or, soup, and bread, .... slices, and milk, .... cup's. 

Or, egg and toast and milk. 

And cooked fruit : Apple sauce, baked apple, stewed prunes or stewed 
dried peaches may be given with any of the above. Give .... table- 
spoonfuls. 

You May Also Give: 

At : Orange juice or grape fruit juice. Eaw apple, scraped. 

At : Broth and crackers. 

At : Graham crackers or 

At : Milk, cup. 

Water. 

One glass may be taken with each meal: never any more at meals. 
Water should be given between meals, but not at bedtime. Boil the 
water ami put on ice to cool. 

Do Not Give: 

Tea, coffee, soda water, beer, wine, whiskey, cider. 
Tried food of any kind (meat, potato, eggs or fish). 
Pork. veal, kidneys, greasy stews. 

Gravy made from grease or drippings. Dish gravy (meat juice) is all 
riofht. 



168 DISEASES OF CHILDREN. 

Candy. It is easier to give none at all. "A little " always means too 

much. 
Sugar, jelly, sweet preserves. 
Fresh bread, cake, pie, fried cakes, rich puddings. 
Nuts, raisins. 
Bananas, berries, cherries. Give no raw fruit of any kind in very hot 

weather. Raw apples must always be scraped with spoon or knife. 
Corn, cabbage, cucumbers, egg plant. 
Too much milk. One quart a day at most is enough for any child. 

Rules for Eating: 

Make every child 

1. AYash hands and face before meals. 

2. Eat slowly and chew food well. 

3. Eat neatly. No child is too young to learn good manners. 

4. Eat what is put before it. Let it go hungry if it will not eat 

proper food. Give no food that is not on the list. 

5. Drink little water with meals. Do not let it wash food down 

with water or milk. 

6. Eest after meals half an hour. 

7. Eat only at meal times. Give no food between meals unless 

ordered by doctor. 

Serve food warm and well cooked on clean dishes and clean table. 

Keep flies away from food. One fly can give typhoid or summer com- 
plaint. 

Good food is as cheap as poor food. 

Do not spoil good food by frying. 

Do not give a child tea, coffee, or beer, and think they are food. They 
are not nourishing at all, and do much harm. 
Milk is the best food, but spoils easiest. Buy only bottled milk, and 
keep on the ice always. 



SECTION V. 
DISEASES OF THE DIGESTIVE SYSTEM. 



CHAPTEE XVII. 
DISEASES OF THE MOUTH. 

General Considerations. 

It is very essential that the normal condition of the mouth be pre- 
served in infancy, as the act of sucking may be impaired and thus result in 
malnutrition of the infant. The mucous membrane of the mouth is par- 
ticularly delicate, and bacterial invasion follows readily any injury to its 
surface. Even well-meant but too vigorous cleansing by the attendant may 
lead to serious mouth disease. Xot until the teeth are present should any 
special effort be made to cleanse the oral cavity. The primary teeth should 
receive regular attention, and the aim should be to preserve them as long 
as possible, and thus ensure a vigorous and well-formed permanent set. A 
soft tooth-brush, used with an up-and-down movement, will effectively 
cleanse the teeth from adhering particles of food, especially if the child 
learns to flush or gargle the mouth after its use. 

The nodules formed near the raphe in infants are normal cystic bodies 
called epithelial pearls, and must not be considered pathological. We have 
seen harm done by measures used for their removal. 

Desquamative Glossitis. 
(Geographic Tongue. Ringworm of the Tongue.) 

The above headings apply to a condition of the tongue in which there are 
areas sharply circumscribed by sinuous borders. The borders are made up of 
enlarged papillae of a dull grayish color which tend to intensify the denuded 
areas. Numerous microorganisms of a low order are found especially in the bor- 
ders of the patches. The variations in the outlines have given rise to the term 
"geographical tongue." It is found among all classes of children; it can only 
occasionally be associated with the derangement of the digestive tract. It gives 
no symptoms, and is productive only of alarm to the mother. It is most com- 
monly seen in children under three years of age. 

Treatment. — The mother should he reassured as to its unimportance. 
Nitrate of silver. \ dram to the ounce, applied with a cotton swab and neutral- 
ized with a salt solution has seemingly arrested the process in a few cases. In 
others it has persisted for months, only to finally disappear spontaneously. 

169 



170 DISEASES OF CHILDREN. 

Simple Stomatitis. 

{Catarrhal Stomatitis.) 

Simple stomatitis is an inflammation of the mucous membrane of the 
mouth, with the chraeteristic symptoms of pain, redness, and swelling, and 
an increase in the normal amount of secretion. 

Etiology. — It is mainly observed in the first year of life, and results 
from some form of irritant, which may be chemical, mechanical, or thermal 
in its nature. Among those commonly causative are improperly prepared 
food, thumb or nipple sucking, and too vigorous mouth washing. Excessive 
use of carbohydrates, especially cane-sugar, may be a cause, and the disease 
is occasionally an accompaniment of prolonged fever due to intercurrent 
maladies. 

Symptomatology. — The babe refuses to take its nourishment or has 
pain while taking it. This should direct attention to the mouth. There 
is marked drooling, and on inspection, redness, swelling and congestion of 
the mucous membrane are apparent. The tongue may be more or less 
coated. The temperature, if elevated at all, is not high. There is no 
adenitis. The restlessness and irritability point to a constitutional involve- 
ment. 

Treatment. — The affection tends to a spontaneous recovery, especially 
if the causative factor is removed. After a few days there is restitution to 
normal conditions. Prophylactic treatment embraces the constant care and 
cleanliness of everything coming into contact with the child's mouth. On 
the other hand, we have observed the inflammation following well-meant 
but too vigorous mouth cleansing. Local applications hasten recovery. A 
1 per cent, solution of nitrate of silver may be brushed over the surface by 
the physician once a day, and a 2 per cent, solution of boric acid is swabbed 
on every two hours by the attendant. 

The following is an excellent and soothing lotion for all forms of sore 
mouth : 

B Sodii sulphit • • • 3j 

Glycerini 3ss 

Aquse rosae < Q-S- ad. Bij 

M. Sig. — Paint over the tongue and inside of the cheeks 
every two or three hours with a camel's-hair brush. 

Order the food diluted one-half and given cold. If the nipple is 
refused in an artificially fed baby, feed with the spoon or dropper. It is 
rarely necessary to resort to gavage. 



DISEASES OF THE MOUTH. 171 

Aphthous Stomatitis. 

(Herpetic Stomatitis, Aphthce, Follicular Stomatitis, Vesicular Stomatitis, 
Maculofib rin o us Stomatitis. ) 

Definition. — A disease characterized by isolated yellowish- white spots 
on the lips, mouth, or palate, surrounded by a reddened mucous membrane. 

Etiology. — Xo specific exciting cause has as yet been firmly estab- 
lished. The weight of evidence seems to point to an infective rather than 
to a neurotic origin, since clinically we have found its spread possible through 
communication. Lack of proper cleanliness is the cause in the great 
majority of cases. Most of the attacks occur during the second year of 
life; and we have in addition to uncleanliness of the mouth and utensils, 
the direct dirt infection produced by the crawling, hand-sucking infant. 
It is also seen occasionally in connection with such diseases as pneumonia, 
gastroenteritis, or the infectious diseases proper. 

Lesion. — The superficial mucous membrance shows a fibroplastic exu- 
date in a localized area, having a reddened areola. The process does not 
go on to ulceration, the mucous membrance healing without scar formation. 

Symptomatology. — Before the lesions are observed it may be noted 
that food is refused or taken with discomfort by the infant. The pain 
causes irritability and disturbed sleep. There is sometimes a low febrile 
reaction. The breath is not foul. The saliva flows freely. After a few 
days the glands beneath the jaw may be somewhat enlarged and painful to 
the touch. Inspection shows a number of whitish spots, which sometimes 
coalesce, on the lips, cheeks, or palate, surrounded by a red ring. The 
pseudomembrane cannot be removed without exciting some slight bleeding. 

Course and Prognosis. — The affection lasts about a week and tends 
to recovery. With proper treatment the course is considerably shortened. 

Treatment. — Prophylactic. This embraces all that was said under 
simple stomatitis, and may be stated in one word — cleanliness. 

Local. — The early application of a 2 per cent, solution of silver 
nitrate, once or twice daily, shortens the disease and makes the infant much 
more comfortable. A 2 per cent, solution of chlorate of potash may be 
applied by the attendant three times a day with a brush. 

General. — A dose of castor oil is usually indicated and helpful. The 
diet should comprise cool milk or gruels until the discomfort has disap- 
peared 

Bednar's Aphthae. 

These are superficial ulcerations which occur in the new-born or in early 
infancy on either side of the palatine ridge at the hamular process. They are 
usually the result of traumatism caused by too energetic cleansing or the suck- 
ing of artificial nipples. This portion of the mucous membrane is normally thin 



172 DISEASES OE CHILDREN. 

and tightly-stretched, and therefore easily abraded. Not infrequently these 
ulcerations are seen following thrush. They are usually bilateral, about the size 
of a small bean, and are covered with a grayish-white necrotic coating which 
cannot easily be washed away. Nursing is interfered with on account of the 
pain they cause. 

Treatment. — Prophylactic. — The proper care of the infant's mouth (see 
p. 170) and the early treatment as in thrush. 

Locally. — The application daily of a 2 per cent, solution of silver nitrate, 
whicn is neutralized by salt solution, will readily effect a cure. 

Perleche. 

This is an ulcerative process superficial in character which appears at the 
angle of the mouth of children of school age. 

Radiating fissures first appear at the corners of the mouth which are brown- 
ish-yellow in color, and soon become covered with desquamating epithelium. A 
gummy exudate contracts the angles, which readily bleed if stretched. Licking 
the lips, no doubt, infects these areas, and prevents healing. Contamination to 
others in the family is occasionally observed. 

Treatment. — Proper advice as to contact infection by kissing, food utensils, 
etc., is to be given. 

Locally, the area is thoroughly cleansed and swabbed with silver nitrate 
2 per cent, or burnt alum. An antiseptic powder such as bismuth subgallate 
may then be applied. 

Mycotic Stomatitis. 

(Parasitic Stomatitis, Thrush, Sprue, Soor, White Mouth.) 

Definition. — This is a local mouth disease produced by the growth 
of a specific cryptogamic fungus. 

The affection occurs most frequently in early infancy. The children 
of the poor, because of parental ignorance or neglect, are prone to the dis- 
ease. Badly or improperly fed infants are subject to this affection because 
of the greater liability to uncleanliness in the feeding apparatus. Marasmic 
and atrophic infants seen in hospital and dispensary practice, seldom pass 
through the first few mouths of life without contracting the disease. 

Specific Cause. — Under. the microscope a small particle of the growth 
appears as a matted fungus microorganism, made up of shreads, composed 
of jointed filaments. Spores are found at the junction of the filaments, 
which reproduced the growth. This particular fungus has not as yet been 
properly classified. 

Symptomatology. — ■ Small rounded white masses appear on the 
mucous membrane of the mouth. The tip of the tongue, and next the 
cheeks and gums are affected. In exceptional instances remoter areas of 
the gastrointestinal tracts, as the esophagus and stomach, are involved. 

As the masses fuse, the characteristic appearance, i.e., sl whitish coat- 
ing resembling milk curd, is seen in the mouth. 

The masses, if an attempt is made at removal, come away with diffi- 
culty, leaving a reddened surface beneath. As the disease progresses, the 



DISEASES OF THE MOUTH. 173 

infant lias difficulty in feeding and will be restless and peevish. There is 
rarely any constitutional disturbance or rise of temperature. Occasionally 
there will be concomitant irritation of the alimentary tract with the pro- 
duction of vomiting and abnormal stools. If the reaction of the mouth 
be taken with litmus-paper it will invariably be found acid in reaction. 
Exfoliation of the pellicles take place after a week or ten days, leaving the 
mucous membrane reddened and glistening. 

Course and Prognosis. — The affection lasts from a few days to a 
week at the most. The exceptions appear in infants with constitutional 
diseases in which thrush appears as a complication; in these it may persist 
for a long time or add to the fatality of the case. 

Treatment. — Prophylactic. — Thrush does not appear in those infants 
who have been properly cared for. The essential prophylactic measures are 
constant supervision and great cleanliness of the infant's utensils, which 
should be boiled and kept for the one infant only; washing the mother's 
nipples, avoidance of harsh mouth washings, removal of soiled clothes and 
diapers, and absolute restriction of all manner of comforters or soothers. 
The diet must be carefully regulated, as infants suffering from this disease 
have nearly always been wrongly fed. (See section on Infant Feeding.) 

Local. — Swab with a 2 per cent, or a saturated solution of boric acid 
(avoid the honey and boric preparations), three or four times a day. and 
follow with copious washing of sterile water. This is curative and sooth- 
ing. In stubborn cases swab once with a weak formalin solution (1/100) 
and then use the boric wash. Sodium sulphite dram one to two ounces of 
water may be used after each feeding. If the nipple is refused, feed with 
a dropper for a few days. 

Ulcerative Stomatitis. 

(^iomocacoe, Putrid sore mouth.) 

Etiology. — This form of stomatitis is found after the second year 
of life, when the teeth have erupted and caries or neglect of the teeth has 
taken place. It follows the infectious diseases, especially measles, and 
result? from the lowered resistance that the previous disease has imposed. 
Bernhem and Pospisil have isolated a bacillus and a spirocha^te. which they 
find quite constantly in ulcerative stomatitis, and they have been able to 
prove a distinct etiological relation. Minerals, such as mercury and phos- 
phorus, are able to produce an ulcerative stomatitis through their irritative 
action. 

Symptomatology. — Attention may be attracted to the child because 
food is refused and pain i> caused by attempts at eating. The breath is 
foul. The tongue is coated. The children are irritable and sleep poorly. 



174 " DISEASES OF CHILDKEN". 

There is a low-grade temperature. They become weak and depressed from 
lack of food. The examination of the mouth shows the gums at first to be 
swollen and red. The lower jaw is commonly involved at some point situated 
on the edge of the gums. A purulent exudate is then formed that goes on 
to necrosis and the formation of an ulcer. As a rule, the preliminary stages 
are not observed. An ulceration on the gum margin which spreads even 
to the buccal portion of the gum is the usual picture. In aggravated cases 
the tooth is exposed and loosened in its socket. The odor is distinctly fetid 
and quite characteristic of this form of mouth disease. Drooling is pro- 
nounced. The cheek and lips may also be involved b\ contact, and 
even necrosis of the jaw may follow in the pathological process. The 
neighboring lymph-glands become hypertrophied. 

Course and Prognosis. — The prognosis depends greatly upon the 
vitality of the child. In poorly nourished, anemic children, it may run an 
obstinate course of several weeks. As a rule, it begins to clear up after 
the first week. 

Differential Diagnosis. — The almost typical picture, with the fetid 
breath, salivation, and localization on the gums, stamps the disease quite 
clearly. In gangrenous stomatitis we have marked and early constitutional 
symptoms and prostration, with a limited dark, purplish area of tissue 
involved. 

Treatment, Local. — The mouth should at once be carefully flushed 
with a mild antiseptic, such as boric acid or peroxid of hydrogen well diluted. 
Eemove the offending carious tooth if present, and then use chlorate of 
potash locally (and also internally, see below), four grains to the ounce, 
applied carefully with a brush or cotton applicator. Silver nitrate in a 
1 per cent, solution locally, is serviceable, if the process is obstinate. If 
necrosis of bone has taken place, surgical intervention is necessary and 
should not be delayed. 

General. — The nutrition should be rigidly kept up and detailed feed- 
ing lists supplied. Milk and eggs made palatable (see diet lists) should 
be forced if necessary. An antiscorbutic diet, such as is described under 
infantile scorbutus is particularly serviceable in these cases. Medicinal 
treatment is confined to the use of the chlorate of potash in 2- to 3-grain 
doses, three or four times a day. It is better not to write for more than a 
three-ounce mixture, as the potash may affect the kidneys if given for too 
long a period. 

Gangrenous Stomatitis. 
(Worn a, Cancrum oris.) 

Definition.— A rapidly developing and usually fatal gangrene, beginning in 
the cheek. . 

Etiology — No specific organism has as yet been satisfactorily proven as 
the causative agent. The disease occurs in children only, most often between 



DISEASES OF THE MOUTH. 175 

the ages of two and five years and rarely in nurslings. Children living in bad 
hygienic circumstances that have had their resistance much lowered by previous 
diseases, especially those that have been confined to hospitals and asylums, are 
more prone to the affection. It may follow measles, diphtheria, typhoid, ulcer- 
ative stomatitis, scarlet fever, enteritis, pneumonia, pertussis, tuberculosis, etc. 
The greater number of cases occurring in this country have followed severe cases 
of measles, and in the epidemic form in institutions, it may there even follow 
mild rases. 

Symptomatology. — A putrid odor from the mouth may be the first symp- 
tom to attract attention. Inspection may then disclose a stomatitis as a fore- 
runner. In other cases there is first observed a swelling of the cheek, which is 
hard, shining, and pallid. Pain is not caused by the examining finger. The 
inner surface of the cheek may show the original site of the infiltration and at 
this point an ulceration is observed. The submaxillary glands, if not as yet 
affected, soon hypertrophy. The infiltrated area in the cheek now becomes dark 
red. and soon is bluish and later black in color. The fetor increases. A line of 
demarcation now appears about the dark area and spreads upward to the eye 
and outward toward the ear. A punched-out area soon appears, permitting 
inspection into the mouth. The gums are correspondingly affected, being covered 
with greenish-gray slough. 

The periosteum may be separated. The teeth are loosened or even drop out. 
There is seldom any bleeding because the process is a gangrenous one. The 
stench is now almost intolerable. 

As may be supposed, the general condition soon suffers from such a destruc- 
tive process. The pulse and temperature are elevated — 102° to 104° F. — with 
a correspondingly weak pulse. 

While at first nourishment is taken and little pain complained of. soon the 
patient succumbs and is badly prostrated. Signs of exhaustion are apparent. 
Patches of bronchopneumonia or a diarrhea complicate the disease. A comatose 
condition with septic rises of temperature usher in the fatal ending. 

In certain cases in female infants the necrosis involves the vulval ring, which 
may soon completely slough out. 

Course and Prognosis. — The course is rapid : the disease may end in a week 
or it may last three weeks from its inception. Only 15 per cent, of the cases 
recover (Moro). Those that do live are left with severe deformities of the face. 

Treatment. — Strict attention to the nasopharyngeal toilet in the infectious 
diseases will tend to prevent this affliction. 

The early and complete extirpation of the diseased area and cauterization of 
the edges is the modern treatment adopted by the surgeons, and the results 
achieved warrant its recommendation. Wherever possible, attempts should be 
made to save the angle of the mouth to prevent a disastrous deformity. Loosened 
teeth or necrotic alveolar structure should be removed. 

Meanwhile, the internist will flush the mouth with a 2 per cent, solution of 
peroxid of hydrogen, or swab with a 5 per cent, solution of nitrate of silver, 
followed by salt solution. 

Nourishment should be forced and stimulation in the form of brandy and 
strychnia given. Turpentine spirits, if kept near the patient, will mitigate the 
nauseating odor. 

Elongated Uvula. 

Although rarely observed, this condition has led to much improper medication 
for persistent cough. The elongated uvula irritates the pharynx and causes a 
cough which is especially marked when the prone position is assumed or when 
the child is overtired. If the chest is negative, this condition should be thought 
of. Treatment is by astringents, applications of silver nitrate, but usually ampu- 
tation is indicated and necessary. 



CHAPTER XVIII. 
DISEASES OF THE DIGESTIVE TRACT. 

Corrosive Esophagitis. 

Etiology. — This condition is caused by the swallowing of caustic chemicals, 
such as potash and sulphuric acid, which produce corrosive burns of the esopha- 
gus. Lye is the most common substance ingested by children. The lesions vary. 
There may be an intense acute inflammation, a necrosis of the mucous membrane, 
or extensive ulcerations which produce cicatricial strictures in healing. 

Symptomatology. — If much caustic has been swallowed, death may shortly 
result ; otherwise there is prostration and vomiting of shreds of bloody mucus, 
or even pieces of mucous membrane may be expelled. The child cannot swallow 
without pain. An erosive hemorrhage may occur after a day or two, or a deep- 
seated cellulitis may result with infection. A stricture is very likely to develop 
in severe cases. 

Treatment. — Appropriate antidotes are to be given if the patient is seen 
early ; such as the acids or the alkalies, depending on the character of the poison. 
The prostration must be combated by supportive treatment, hypodermatic injec^ 
tions of camphor or strychnia. For the intense pain, codein subcutaneously will 
be indicated. Olive oil thrown into the esophagus is a distinct advantage, and if 
the child can swallow, this should be regularly administered. The treatment of 
the stricture is surgical. The string method has given some brilliant results in 
cases coming under our observation. Gastrostomy may be necessary to preserve 
the life of the child if sudden occlusion of the esophagus results. 

Congenital Occlusion of the Esophagus. 

This condition is rarely observed. Difficulty in swallowing and the regurgi- 
tation of even the smallest quantities of food should lead to an investigation 
with the bougie. The atresia or stricture is usually situated at or near the 
bifurcation of the larynx. 

Acute Gastric Indigestion. 

(Acute gastritis, acute dyspepsia, acute gastric catarrh.) 
Etiology. — Errors in diet are the principal cause. In infancy the 
quality and quantity of the milk, or the irrational use of extraneous articles 
added to the dietary act as causes. Improper feeding habits will bring 
on occasional attacks. Sweets, unripe fruits, and pastries in older children 
or even large quantities of one kind of food may produce an attack. 
Usually there is more or less involvement of the intestinal tract. 

Symptomatology. — The symptoms very often begin suddenly with 
fever, headache, abdominal pain, and vomiting. The temperature may 
reach 104° F. with a correspondingly high pulse rate. The vomiting is 
repeated several times, and the evidences of undigested food, or a certain 
article of food which has caused the attack, as unripe fruit, are seen therein. 
The patient is chilly at times and apt to be sleepy. Food is abhorrent, the 
tongue is coated with a thick fur, and the breath is disagreeable. Occasion- 

176 



DISEASES OF THE DIGESTIVE TRACT. 177 

ally convulsions occur, especially in neurotic children. After the vomiting 
ha? ceased or a (compensatory) diarrhea has set in, there is relief from the 
distressing symptoms, although nausea and vomiting may reappear if the 
child is pressed to eat. 

Prognosis. — This is usually very favorable, although the onset of 
convulsion in a weakly infant would warrant a guarded prognosis. 

Treatment. — In breast-fed infants, examine the mother's milk, and 
give plain boiled water until vomiting and fever have subsided ; a cleansing 
enema will complete the cure if the milk is not permanently abnormal. 
Bottle-fed infants surfer often from this malady, and the food formula and 
its preparation should be inquired into most minutely, for well-intentioned 
attendants often make grievous errors. Calomel gr. i in divided doses every 
ten minutes will clear the bowels. If there is a convulsion, clean out the 
bowels at once with an enema and later wash out the stomach if vomiting 
has not been free. In all cases the patient should be put to bed, without a 
pillow, and a mustard paste applied to the epigastrium in the strength of 
one to seven of flour. The fever is controlled by sponging with alcohol and 
water. Dietetic management is very important. Infants may be kept on 
albumin water, cereal decoctions, or whey, and then gradually returned 
to their regular feedings. Older children are not allowed to take any food 
for twelve to twenty-four hours, except sips of cold water. Then beef tea, 
toast, and crackers are allowed and later milk, milk toast, etc., slowly 
returning to the regular diet. 

Gastric Ulcer. 

While this disease ia not of frequent occurrence during childhood, it may 
happen at any period of life, even during infancy. Stowell has collected thirty- 
five eases from birth up to puberty, the earliest at five days, and six during 
infancy. 

Etiology. — The following conditions may act as causes: Hyperacidity of the 
stomach with spasm of the pylorus, swallowing sharp substances with resultant 
local injury, various infectious diseases and septic conditions following birth, 
extensive burns, thrombosis of the umbilical vein and embolisms in the stomach 
wall. 

Pathology. — In young infants there may be melena. usually from sepsis, 
and blood may be passed in the stools presenting a dark appearance from iron 
sulphid produced from the hematin of the hemoglobin. The ulcer may be located 
in any part of the stomach, but is most commonly situated in the lesser curva- 
ture. In cases that perforate, the site is most often on the anterior wall. 

Symptomatology. — During infancy the principal symptom may only be a 
constant irastrir- irritation and indigestion with occasional hematemesis. or the 
vomitus may simply be streaked with blood. If there is sufficient blood to pass 
into the bowel, dark, coffee ground masses may appear in the stool. Vomiting, 
however, is not such a constant symptom in early life as in adults. Pain is a 
fairly uniform symptom : It is aggravated at once by taking food, especially 
sugary or rich preparations, and relieved by vomiting. Pain can also usually be 
elicited by pressure over the stomach. The imperfect digestion and disinclina- 
tion to take food soon result in progressive emaciation. Constipation is often 
1? 



178 



DISEASES OF CHILDREN. 



present and profound anemia may result if healing does not soon take place. If 
perforation or severe hemorrhage occurs, there will be the usual symptoms of 
marked collapse. 

Diagnosis. — This must depend upon constant gastric irritability, blood in 
vomitus or stools, pain immediately after food which is relieved by vomiting, 
and pain on local pressure. Jacobi has given the following interpretation of the 
relation between pain and the ingestion of food : Pain half an hour or an hour 
after food points to duodenal ulcer, or peritonitic adhesions of the duodenum ; 
pain three or four hours after a meal may be referred to the colon ; pain most 





J/ 


, 




y k4 










~- 


* v • - • v -r-,"-.. '">■./ - 


- * 


c 


V 





Fig. 52. — Ulcer on lesser curvature : infant 7 months old. 



marked when the stomach is empty and relieved by food usually indicates a 
neurosis. 

Treatment. — The patient should be given easily digested food in small 
amounts at frequent intervals. Peptonized milk or skimmed milk and gruels, 
buttermilk, dextrinized gruels, light cereals and egg water may be tried. The 
acidity of the stomach may be lessened by the simpler alkalies, such as calcined 
magnesia, milk of magnesia, carbonate of lime and similar preparations. The 
stomach may be partially rested by rectal feeding. If pain is severe, bismuth 
subcarbonate and small doses of codein may be employed. In cases of perfora- 
tion, surgical treatment is indicated. This, fortunately, is rare. 



DISEASES OE THE DIGESTIVE TRACT. 179 

Chronic Gastritis. 

Definition. — A chronic disturbance of the gastric function, associated 
usually with a similar involvement of the intestinal tract. 

Etiology. — Improper feeding at irregular intervals is the main cause. 
especially when coupled with bad hygienic living. Rickets, tuberculosis, 
and chronic affections of the liver predispose to a chronic gastritis. Among 
pampered children it results from the use of sweets, pastries, and rich 
dressings which the child is allowed to have. 

Symptomatology. — Frequent vomiting first attracts the attention of 
the parent. This after a time follows each meal. There are eructations of 
gas and a feeling of discomfort after eating. The tongue is coated. The 
appetite is capricious. The outline of the stomach shows a well-marked 
dilatation. The abdomen remains quite persistently distended in spite of 
medication. The child is fretful and restless in sleep; the weight falling 
off gradually in aggravated cases. In infancy the picture of marasmus 
may be seen. Periods of prostration and collapse may precede a lingering 
death. Older children show no inclination to play, slowly grow more feeble 
and flabby : mucus is seen with greater regularity and in greater quantity 
in the vomitus. 

Diagnosis. — From a basilar meningitis the disease may be distin- 
guished by the absence of stupor or coma and lack of reflex changes. In 
doubtful cases the Von Pirquet reaction or a study of the spinal fluid 
could be resorted to for verification. Pyloric stenosis should be excluded by 
careful physical examination and the character of the vomiting. 

Course and Prognosis. — The disease may last for weeks and the child 
drag on a miserable existence until it succumbs to a terminal disease, such 
a 3 bronchopneumonia or marasmus. Infants rarely withstand the disease, 
while if they survive they are apt to be weak and puny. In older children 
the prognosis is better and treatment of greater avail, although convalescence 
is prolonged sometimes through months. 

Treatment. — If all children were brought at stated intervals to their 
physician for examination and counsel, whether well or ill, chronic gastritis 
would be a much rarer disease. " Proper food properly given " is the 
prophylactic treatment. The treatment is mainly dietetic. A careful 
history and study of the previous diet is the first requisite. Find the factor 
that is causing the disturbance: determine whether it is the butter fat. 
carbohydrates, or protein elements, for example, that is at fault. The 
periods of feeding, the quantity, the quality, and the digestive ability of 
the stomach itself must be weighed in the balance and corrective measures 
instituted as described in the chapter on Tnfant Feeding. The fact must 



180 DISEASES OF CHILDREN. 

not be lost sight of that some children cannot digest cow's milk in any 
form. For the correction of the vomiting and to control the failing nutrition 
it is necessary to supply such food as will meet the lowest nutritional 
requirements, and in as readily a digestible form as possible. It is well to 
wash out the stomach before beginning the treatment. The legume flours, 
as pointed out by Edsall and Miller, are excellent substitutes for cow's milk 
if it disagrees, and they furnish sufficient protein to keep up nutrition. 
Beef blood, yolk of egg, and gruels are to be tried, and if they agree, that 
is, cause no vomiting, may be alternated so that they will not pall on the 
appetite. If an increase in weight is obtained, weakened regular milk 
feedings may then be cautiously tried. Occasionally the stomach-tube must 
be used in obstinate cases. Rectal feeding is without much merit in these 
cases. Children two to three years old are often benefited by a change to 
the seashore. The appetite is thereby stimulated and the strict dietetic 
regime more willingly followed. A special diet list should be prepared 
by the physician for each case. From this should be excluded all sweets, 
gravies, and pastries. Milk, gruels, eggs, and the softer vegetables should 
be the mainstay. Coupled with the dietetic management, the daily routine 
of the child should be outlined. A fresh-air life, plenty of sleep, plenty of 
water to drink, and agreeable baths are necessities. Cases seen late or doing 
badly require stimulation, and this is best given in the form of the tincture 
of mix vomica three minims well diluted one-half hour before meals. Con- 
stipation is relieved by milk of magnesia or cascara in children or with a 
suppository in infants. 

Dilatation of the Stomach. 

Etiology. — This condition results from causes which tend to weaken the 
muscular walls of the stomach. It is more commonly observed in infants suffer- 
ing from constitutional diseases, such as rickets, marasmus, syphilis, and tuber- 
culosis. Among the rarer causes are pyloric hypertrophy or stricture. 

Symptomatology. — Those which result in the course of the constitutional 
diseases will be here described. Vomiting occurs usually some time after meals; 
food is not taken with avidity, and later in the disease may be abhorrent. Con- 
stipation is a noticeable symptom. The abdomen is usually tympanitic, tongue 
coated, and in older children headaches may be complained of. 

Physical Examination. — In emaciated subjects the greater curvature of the 
stomach may be seen on inspection. The abdomen is generally prominent, but 
percussion over the dilated viscus gives a highly resonant tympanitic note. If 
fluid is present a succussion note can be obtained by tapping with the ends of the 
fingers. If the diagnosis is still indefinite, water or air may be introduced as an 
aid in determining its size and capacity. 

Prognosis. — Unless due to a congenital stenosis, the prognosis is fairly good, 
but the course is slow and dependent upon the underlying disease. In itself the 
condition may retard the progress of a case of rachitis, for example, or even 
become the factor that may lead 'to a fatal termination. 

Treatment. — The motor inactivity necessitates in the beginning a course of 
gastric lavage coupled with dietary regulations as outlined under the article on 
Chronic Gastritis. Fresh air, massage, electricity, or vibration will be additional 



DISEASES OE THE DIGESTIVE TRACT. 



181 



aids, no matter what the underlying disease. The tincture of mix vomica in 
small doses will stimulate the appetite and assist the motor functions. If the 
disease is dependent upon a stricture, radical measures may be necessary to effect 
a cure. 

Stenosis of the Pylorus and Pyloric Spasm. 

(Congenital hypertrophy of the pylorus.) 
This is a condition in infancy in which there occurs an obstruction 
to the passage of food from the stomach as a result of hypertrophy or spasm 
of the pylorus. 




Fig. 53.— (a) From a case of congenital hypertrophic pyloric stenosis: 
infant six weeks old — seen by one of us. (h) section of tumor in same case. 

Etiology. — There are no positive etiological factors known. 

Pathology. — The muscular, and occasionally the connective tissue at 
the pylorus, is hypertrophied. The stomach is dilated and thick tenacious 
mucus is found on the mucous membrane. 



182 



DISEASES OF CHILDREN. 



Symptomatology. — The disease is usually not recognized when the 
first symptom appears. An apparently healthy infant at the breast may 
begin to vomit after nursing. This being repeated at frequent intervals, 
advice is sought. The usual corrective measures do not suffice and the 
vomiting is more persistent. Closer observation will show that the stools 



■:...■■..■■■■:■ 


1 






' 


(G* 




Fig. 54.- 



Wave in a case of pyloric 
obstruction. 



Fig. 55. — Pyloro-spasrn : little food 
only has been extruded as compared 
with normal stomach. 



are extremely small, that the urine is scanty, and that the vomitus 
is projectile in type. The diagnosis now" becomes more apparent. Phys- 
ical examination may show a thickening about the pylorus, espe- 
cially if anesthesia is used, but this is not always present. The 
cases of simple pyloric spasm do not give evidences of tumor formation; 
the vomiting is not quite so persistent, and the emaciation not so rapid. 



DISEASES OF THE DIGESTIVE TRACT. 183 

The stools are small and like dry putty, sometimes alternating with diar- 
rhea. Owing to the obstruction, little or no chyme enters the duodenum, 
and progressive emaciation results. The stomach is dilated, but the 
intestines are collapsed, a valuable sign in this disease. A peristaltic wave 
may be observed passing from left to right upon slight mechanical stimula- 
tion. Examination of the stomach contents shows a mixture of food and 
mucus, but without any bile. Hyperchlorhydria may be present. If 
measures for relief have not been successful the child dies of starvation. 

Diagnosis. — The characteristic vomiting without dietetic error, visi- 
ble peristalsis, and a palpable tumor are of especial diagnostic importance. 
If to these are added the sunken abdomen and progressive emaciation, the 
diagnosis should be more certain. 

Course and Prognosis. — In cases of true stenosis, due to hypertrophy, 
the course is progressively downward and, unless there is successful inter- 
vention, ends fatally in six to ten weeks. Cases that have been cured by 
medical treatment alone are probably those in which there was spasm only 
present and not a true stenosis. It is certain that the older the infant 
becomes before symptoms appear, the better its chances for recovery. 

Xotable achievements have lately been made in Roentgenology, 
especially with the use of bismuth in the alimentary tract. 

The fact that we may be able to observe the exit of food into the 
duodenum within a minute or two after its intake rather tends to show 
that we may have been overvaluing this portion of the alimentary tract. 

That liquid foods begin normally to be expelled in a very short time 
after they are taken into the stomach is very helpful in our diagnosis of 
conditions dealing with some form of pyloric obstruction, for, if we can 
demonstrate, with a degree of exactness, by a series of radiographs, that 
the milk is retained for a greater length of time than in a normal stomach, 
as shown by the bismuth shadow, we can determine with a fair degree of 
certainty with what type of obstruction we are dealing. If such striking 
results can be obtained by this means, it would seem manifestly unfair not 
to early obtain a series of radiographic pictures in every suspected case, so 
that the infant, suffering from a true tumor with a lumen so small as to 
practically occlude the passage of food into the duodenum may be early 
given over into the hands of the surgeon while its physical condition is still 
good. On the other hand, cases of pyloric spasm, even of marked degree, 
but without tumor formation, can be differentiated, since the time and 
the amount of the food passing through the pylorus can be seen and. thus 
the diagnosis, and even the prognosis, can be fairly well fixed. 

In every suspected case of pyloric obstruction a radiographic study 
should be made before a plan of treatment is determined upon. 



18-4 DISEASES OE CHILDREN. 

Treatment. — As soon as the diagnosis is made, stomach washing should 
be regularly done twice a day with bicarbonate of soda, one dram to the 
pint. The food, preferably breast milk, should be fed by gavage and always 
after the stomach washing. 

Cyclic Vomiting. 

(Recurrent Vomiting, Periodic Vomiting.) 

This symptom-complex occurs in older neurotic children and is char- 
acterized by periodical attacks of vomiting and prostration, usually without 
fever and without marked indiscretions in diet. 

Etiology. — The condition is usually ascribed to some form of tox- 
emia. Children from five to twelve years of age are more frequently affected. 
It is more apt to occur in the families of the well-to-do than in the poor. 
Metabolism is disturbed, as shown by the presence of the acetone and 
diacetic acids in the urine. Edsall believes that in the majority of cases 
faulty digestion is the underlying factor. 

Symptomatology.— In cases already under observation, a prodromal 
stage may sometimes be detected, but for the most part the attack comes on 
suddenly in children who are considered to be in good health. Occasionally 
constipation, lassitude, loss of appetite and a slight temperature precede 
the attack. The vomiting is persistent, recurs frequently and sometimes 
contains blood; nothing is retained. The child soon shows the effects of 
the strain, lying quite prostrated with sunken eyes, anxious expression, 
coated tongue, sweetish breath, and a high pulse. Thirst is a prominent 
symptom and cannot be relieved on account of the vomiting. The abdomen 
becomes scaphoid in shape, and sometimes is sensitive to the touch. Con- 
stipation is almost the rule. There may be periods in which vomiting 
ceases for a short time and some fluid or food can be temporarily retained. 
The attacks recur in varying periods — it may be weeks or months. The 
urine when examined is found deficient in amount and clouded, and usually 
gives a marked acetone reaction. Indican, diacetic acid, and occasionally 
albumin, and casts are found. Eecovery is quite rapid when the attack has 
ceased and food can be retained. 

Diagnosis. — This must be made after excluding acute gastritis, men- 
ingitis, nephritis, and appendicitis. The sudden onset, acetone breath, 
absence of high temperature in a child without a history of dietary 
indiscretion, would call attention to this symptom-complex. 

Prognosis. — As to life, the prognosis is distinctly favorable, although 
a few fatal cases have been reported. The attacks tend to recur unless the 
underlying cause be removed. 



Plate B. 




Cover-glass preparations stained with the Weigert-Escherich MODIFICATION OH 

Gram's Stain (x ca. icoo). 

1. Meconium. 2. The blue bacillus of E^cherich. 3. Faeces of a breast-fed infant. 

4. Faeces of a bottle-fed infant. 5. Faeces of an adult on a carbohydrate diet. 

6. Faeces of an adult on a meat diet. 

By permission. J rout Cammidge, ''Examination of Fcrccs.'' 



DISEASES OF THE DIGESTIVE TRACT. 185 

Treatment of the Attack. — Rest of body and stomach are essential ; 
nothing should be given by mouth. To allay the thirst, colonic irrigations 
of normal salt solution, allowing four to six ounces to be retained, are 
effective. If the attack persists beyond the second or third day, codein 
hypoderniatically may be necessary, followed by nutrient enemata of 
peptonized milk and whiskey. Four to six ounces or 4 per cent, dextrose 
solution ma} T be given livpodermatically with good effect in markedly 
prostrated cases. Small doses of carbonated water may be tried when the 
vomiting begins to abate. Later, hot broths, dextrinized gruels, orange 
juice and semisolid food is offered until convalescence is established. 

In the Interval. — This should be influenced by the family history. 
the dietetic faults, and an examination of the urine. The child should be 
under constant medical supervision. A suitable diet should be prepared and 
its effect on the urine noticed. School work must be lightly undertaken, 
and parties and strenuous playmates prohibited. The bowels should never 
be allowed to become constipated. A specific amount of water should be 
given daily. The daily life of the child must be apportioned, as in this 
way only, may we hope to prevent recurrences. If the child has ever had 
an attack of appendicitis, this structure should be removed. 

Stools. 

The stools of the breast-fed infant may be from one to five in number, 
and numerically we should not judge them as abnormal, provided their 
color, consistency, and odor are within the normal limits. Their color 
should be a yellow or orange tint with homogeneous consistency produced 
by the unchanged bilirubin. Their reaction should be acid and the odor 
not disagreeable. The amount of residue found in the stools will be in 
direct proportion to the amount ingested or retained. The latter statement, 
however, does not hold true for the babies artificially fed. 

Stools of Artificially Fed Infants. — Cow's milk normally produces 
a stool lighter in color, bulkier, and numerically fewer. The feces amount 
to about 5 per cent, of the food ingested. In the hand-fed infant the 
protein elements are longer exposed in the intestinal canal to putrefaction. 

Examination of Stools. — If we examine a freshly passed stool from 
an infant fed on human milk (See PI. B, fig. 3), and with an improvised 
spatula spread out a central portion, we may find that there are yellow 
masses or flakes present ; these are often mistaken for curds, but in reality 
are made up of fats: firm, hard curds are not found in mother's milk — 
only in cow's milk. Such a stool in an infant not steadily gaining would 
indicate a scanty milk supply, and if the stools were frequent, dark green 



186 DISEASES OF CHILDREN. 

and mucoid, with very little milk residue, the maternal font would surely 
be found to be at a low ebb. The indication would be wet-nursing or 
alternate feedings and regulation of the diet and life of the nurse. 

In the bottle-fed baby we are often confronted with the symptoms of 
constipation or diarrhea. Either of these conditions may arise from too 
much protein in the food. The constipated stool will be friable, like dry 
putty, while the loose stool due to this cause can be smoothed out and the 
masses will be readily soluble in ether, proving them to be fat and not 
curds, as they are so often designated. 

True curds are formed in the stomach by the action of lactic acid or 
an excess of hydrochloric acid and rennet on the paracasein. They are hard, 
smooth, yellowish on the outside and white within, with a cheesy odor 
when opened, and will not dissolve in ether. The remedy for too much 
protein is evident. Correct the formula, and if true curds are present, 
examine the character of the milk. The milk may have been sterilized or 
it needs to be mechanically diluted with gruels, or chemically modified, 
when the stools will assume the normal type. A loose, greasy, sour-smelling, 
acid movement, resembling scrambled eggs, will indicate excessive fat in the 
dietary. Examination of the breast milk or a study of the formula will 
show that the fats ingested have been persistently too high. Three per cent, 
of fat should never be exceeded by an infant to the third or fourth month, 
and more than four per cent, should never be prescribed. It should be 
recollected that a certain amount of fat is always present, but should not be 
visible in distinct masses. 

Mothers often erroneously speak of large quantities of mucus as pres- 
ent in the baby's stools. The doctor must remember that some mucus is 
normal ; that it should, however, be found intimately mixed with the feces. 
Barley water produces a slimy stool often mistaken for mucus, and undi- 
gested food elements also cause this error. If mucus is seen in any quan- 
tity with the naked eye by a competent observer, it is pathological and 
means inflammation, usually located in the large intestine, of a subacute or 
chronic form. If the disease is in the small intestine, the mucus is mixed 
with the stool and it is usually found to be bile-stained. The hint for cor- 
rection is embodied in the following fact — that the greater the amount of 
nonassimilable substances present, the greater the amount of mucus. The 
color of the stools when immediately passed should be considered. If the 
absorptive process has been delayed and putrefactive changes have taken 
place in the protein element, the bilirubin will be changed to biliverdin, 
but it is not known whether the reaction itself, or chromogenic bacteria, pro- 
duce the coloration. Nitric acid will prove whether or not we are dealing 



DISEASES OE THE DIGESTIVE TRACT. 187 

with bile salts by the familiar play of colors. The green color in conjunc- 
tion with mucus, and fecal acid reaction, indicate true intestinal disease, and 
call for radical change in the dietary. Acid fermentation will require such 
temporary food as albumin water for its correction, while alkaline putre- 
faction will respond to the carbohydrate foods, as dextrinized gruels. The 
brownish movements often seen, if we exclude certain drugs and blood, 
are due to the ingestion of undextrinized starches alone, or a preponderance 
of carbohydrates in proprietary infant foods (See PI. B, fig. 5). 

A stool that presents a foamy, bubbling appearance and is acid in 
reaction will signify the presence of too much sugar in the mixture, as is 
often the case in canned condensed-milk feedings. 

We have not hinted at the bacterial examination of the stools, as it has 
proven of no clinical value as yet. The reaction of the stool is a help and 
should be ascertained, and always taken from the middle of the fresh stool. 
If a blue color is obtained, we have alkaline protein putrefaction going on, 
and if the color of the litmus is unchanged, we have acid fermentation due 
to the breaking down of the fat and carbohydrates. (For further tests see 
page 49.) 

Again, the stools may be of considerable aid to us in certain patho- 
logical conditions, as illustrations of the intensity of the process in the 
summer diarrheas, and in such pathological states as intussusception, in 
which we have frequent paroxysmal discharges with blood and mucus, but 
no feces. Rectal polypi should be strongly suspected where we have a normal 
stool, except for a fresh-blood coating; these hemorrhages being intermittent 
in character and not necessarily connected with a hard or scybalous mass. 
Fissures may be produced by hard fecal masses and have a blood coating, 
or in their passage produce bleeding from the rectum. Dark grumous 
blood mixed with the feces is indicative of hemorrhage, higher up in the 
bowel — probably from intestinal ulcerations. In gastric or acute duodenal 
ulcer there is vomiting of blood and mucus, but there is no fresh blood in 
the stools. 

Colic. 
(Enteralgia.) 

The term colic is used to designate the paroxysmal pains which occur 
in the abdomen. It is a symptom and not a disease, and usually denotes the 
presence of an abnormal amount of gas in the intestines, which stimulates 
undue peristaltic movements. 

Etiology. — It occurs most frequently in artificially fed babies, as a 
result of digestive disturbances dependent upon the food ingested. This 



1S8 DISEASES OE CHILDREN. 

food may have been unwholesome, too great in amount, or one of its con- 
stituents may have been in excess. For example, the percentage of proteins 
in a given mixture may be too high, or the sugar may cause fermentation if 
present in undue amounts (beyond 6 per cent.), or there may be starchy 
indigestion. Breast-fed infants may suffer from a poorly balanced milk 
or from overfeeding or too hasty nursing, 

Colic occurring in the course of other disease is dependent upon the 
resulting atonic condition of the intestinal walls. 

Symptomatology. — The attacks come on suddenly, the infant is 
restless and uneasy, and cries unceasingly. The abdomen is distended and 
rigid and the thighs are drawn up over the abdomen. The extremities may 
be cold. If during the examination some flatus is expelled the screaming 
ceases and the evidences of relief are apparent. 

Treatment. — In the attack, heat should be applied to the abdomen, 
an enema of warm saline solution should be given and sips of hot water 
given by mouth. These measures will usually be effective. If relief is 
not obtained, massage of the abdomen with warm olive oil, followed by a 
hot colonic irrigation containing two drams of the milk of asafeticla to four 
ounces of water can be used. 

The following prescription may be of occasional service : 

B- Chlorali hydrati gr. viii 

Sodii bicarbonatis gr. x 

Sodii bromidi 3ss 

Aquae menthae pipertae jfss 

Aquae q. s. ad §ij 

Misce et signa. — Give a teaspoonful in a little hot water every 
two or three hours. 

The further treatment resolves itself into efforts to discover the cause 
of the cclic. The details of the preparation and administration of the 
infant's food may disclose a fault worthy of correction. The care of the 
mother or wet-nurse must not be forgotten when colic is present in the 
breast fed. 

Acute Gastroenteritis. 

(Summer Diarrhea. Summer Complaint. Infectious Diarrhea.) 
Etiology. — Artificially fed babies in the hot, humid summer months 
are especially prone to this infection, superinduced by the ingestion of 
unwholesome milk. Infants and children under two years are mainly 
attacked. The children in the tenement-house districts of our large cities 
show the greatest morbidity to infectious diarrhea. Although a lowering of 
the body resistance by the heat serves to produce the disease, the specific 
factors are organisms of the bacillus dysenteric type, gas bacilli, colon, 
strepticoccus and the pyocyaneus bacillus. The bacillus dysenteric (Shiga- 



DISEASES OE THE DIGESTIVE TRACT. 189 

Flexner bacillus) can be isolated from many of the stools. The infection 
is usually from without, but autoinfection is possible. The lack of refriger- 
ation, the feeding of food unfitted to the age, plus the devitalization by the 
summer heat, makes infection easy and common. Babies in crowded 
hospital wards may become infected by careless handling of the soiled 
diapers. 

Pathology. — Xo special characteristic may be observed at necropsy, 
except a congested mucous membrane in the stomach and small intestine, 
with enlarged lymph glands. As a rule the Peyer's patches and solitary 
follicles are prominent with occasional ulceration of these areas. It is rare 
to find lesions outside of the large intestine and the last section of the 
small. Cloudy swelling of the kidneys is quite constant. 

Symptomatology. — Mild Form. — The stools first attract attention. 
They are curdy, loose and somewhat foul. Soon mucus and blood-streaked 
fecal matter appear ; the child is restless, loses its desire for food, and may 
vomit if the food is urged. The fever is moderate and the child fretful. 
The character of the stools soon changes to a greenish-yellow, and they 
become more numerous, five to six a day, and the fever rises to 102° or 
103° F. If prompt measures, as indicated below, are taken, recovery is 
rapid and quite certain. 

Severe Form. — Here the onset is quite sudden, and the predominat- 
ing symptom is the marked diarrhea. The numerous small, green, foul- 
smelling stools, often with a putrefactive odor, contain much mucus and 
are blood streaked. Eestlessness and pain disturb the sleep, and the child 
rapidly becomes emaciated. After a few days, if the numerous stools con- 
tinue, tenesmus and vomiting ensue, the patient often refusing any food. 
The abdomen becomes sunken and the rectum is apt to protrude from the 
frequent movements, the fontanel in infants becomes sunken, and the pulse 
thready, the fever rises to 104°-105° F. with few remissions, the urine 
becomes diminished, and symptoms of meningeal irritation may supervene. 
Except for a moderate increase in the polynuclears, fifteen to twenty 
thousand, the blood offers nothing characteristic. 

Toxic Form. — From the onset the symptoms are unusually severe. 
High fever and intense prostration are added to the incessant vomiting and 
frequent stools. The color of the stools is constantly green, the odor ex- 
tremely foul, and blood-streaked mucus appears early. Cerebral symptoms 
soon supervene, delirium and coma usher in the end. which may come on 
in a day or two. or even within twenty-four hours. In this form the Shiga 
bacillus can usually be demonstrated. 



190 DISEASES OE CHILDREN. 

Course and Prognosis. — This has been indicated under the separate 
divisions, depending upon the severity of the infection. If seen early, the 
mild and severer forms are amenable to treatment, although a guarded 
prognosis is always advisable. The toxic type is apt to baffle even the 
most heroic measures. The ability to command good nursing and later 
change of climate naturally influence the prognosis. Cases responding to 
treatment usually clear up within two weeks. The previously enfeebled 
infants may go on to a condition of chronic gastro-intestinal indigestion. 
(See page 194.) Signs of meningeal irritation (meningismus), prolonged 
high fever, uncontrollable vomiting, or convulsions indicate a grave prognosis. 

Treatment. Prophylactic. — Breast-feeding whenever possible, es- 
pecially in the summer months, is desirable. Cleanliness and care in every 
detail of the child's diet and clothing are necessary. The use of pasteurized 
or constantly refrigerated clean milk is indicated. Proper disinfection of 
stools and the nurse's hands must be insisted on. Eegulation of the diet, 
according to the heat and the condition of the infant, will help in pre- 
vention. Weak infants are more susceptible in the second summer. 

General Management. — Place the patient in the coolest, cleanest and 
largest room possible. A cotton slip and diapers only are to be worn in 
hot weather. Secure a competent nurse to intelligently follow orders. Ke- 
duce the fever by frequent cool sponging with a fifty per cent, alcohol 
solution, or by tepid sheet packs, or by reducing the temperature of the 
water used for colon irrigations to 95° or even 90° F. If the temperature 
is above 104° F. and the pulse permits, use an ice-bag to the head. A 
satisfactory initial purge with castor oil or calomel is indicated. 
One, or at most two, bowel irrigations of normal saline solution are to 
be given from a fountain bag as indicated under entroclysis (page 74). 
Where there is much tenesmus, starch enemata may be given. In conval- 
escence, or in the sub-acute form, a pint of a two per cent, silver nitrate 
solution may be allowed to gently flow into the colon, to be retained as long 
as possible. For the prostration, water must be offered freely, and if not 
retained it should be given by the drip method by rectum, or four ounces 
may be given subcutaneously. When no food has been retained, much 
benefit can be derived by adding two or three per cent, of dextrose to the 
solution. This may be given four times in the twenty-four hours. 

Since no dependence can be placed upon intestinal antiseptics, and 
since bismuth has been practically discarded, the drugs that are used are 
the stimulants, and very occasionally, the sedatives in the form of Dover's 
powder, after the toxic symptoms have subsided. Caffein, particularly in the 
form of sodium benzoate, is the preferable stimulant. It may be given to 



DISEASES OF THE DIGESTIVE TRACT. 191 

an infant in quarter to a half grain doses alone, or alternating with strych- 
nin sulphate 1/240 of a grain, every four hours. 

Dietetic. — Stop milk in all forms for at least twenty-four hours, 
placing the child on a starvation diet of boiled water alone or on barley 
water, made with one ounce of flour to the quart. If at the end of a day 
the frequent stools persist, continue the substitute feeding a day longer 
until a change for the better is noticed. 

If barley gruel is not palatable or tolerated, one may try rice water or 
albumin water. (See section on Dietetics.) In the case of nurslings re- 
sume the feeding at longer intervals preceded by a dram or two of boiled 
water. Substitute feedings such as barley water must not be continued too 
long a time as the infant's life may be jeopardized by too prolonged starva- 
tion. Morse has pointed out that the character of the food offered should 
depend upon the type of organism producing the diarrhea. Unfortunately 
it is rarely practicable, except where trained laboratorians are at hand to 
do this. It is demonstrable, however, that cures are more readily effected 
if carbohydrates are offered when the infecting organism is dysentery or 
colon bacilli, or a streptococcus; while the gas bacillus and its prototypes 
do best on protein, fat-free food. (See buttermilk feeding and Eiweiss 
milk.) This dietetic test is suggested in outlying districts where laboratory 
aid is not available. When Eiweiss feedings are used the nipple must be 
perforated to permit the flow of the particles of casein. It is sometimes 
necessary to add a grain of saccharine to a pint of mixture to make it palata- 
ble. The stools change from a thin watery consistency to a heavy pultaceous 
mass, decrease in number, thereby adding to the comfort of the child. 
Unfortunately we do not meet with success in all cases, by this method. 
It is worthy of a trial, however, when the above mentioned directions do 
not succeed. The stools having in any instance assumed a more normal 
appearance, skimmed milk, diluted if necessar}*, is fed before returning to 
the proper modification. In artificially fed babies, resumption to cow's 
milk feedings must be made only when the stools begin to resume the 
normal type. Begin with a modification lower than the original 
prescriptions. 

The diarrheal diseases of infancy and childhood do not permit as yet 
of any definite classification, for the etiological factors may be the same 
in a number of the allied affections, and the various pathological changes 
found are often those of degree or situation only. It is to be hoped that in 
the near future these grouped diseases may be more accurately separated 
and defined. 



192 DISEASES OE CHILDREN. 

Acute Enterocolitis. 

Definition. — This is an inflammation of the mucous membrane of 
the small and large intestine associated with ulcerations and characterized 
by tenesmus and blood-stained stools. 

Etiology. — Children in the summer months, especially those who have 
had previous attacks of gastroenteritis, or who suffer from chronic indiges- 
tion, are especially liable to attack. The children of the poor in the large 
cities because of improper food and uncleanliness are most frequently the 
victims of the disease. Such constitutional conditions as rickets, tubercu- 
losis, and syphilis are predisposing elements. The Shiga bacillus and its 
prototypes are found in a great many of the cases. 

Pathology. — In the colon and about the ileocecal valve the charac- 
teristic lesions are commonly observed. In some of the lighter forms of 
the disease we find only evidences of congestion and inflammation with a 
roughened or somewhat denuded epithelium. 

The lymphatic structures are hypertrophied or show loss of tissue. 
If the affection has been of a severer grade, the follicles are degenerated, 
producing a slight ulceration and consequent uneven feel to the gut. These 
changes are commonly seen in the colon and rarely in the ileum or rectum. 
In the usual type seen after a severe illness quite deep ulceration may 
exist, so as to produce a shaven beard appearance. The ulcers may later 
extend down to the muscular layer, and a large area of ulceration may be 
found by the coalition of a number of smaller ulcers. Another type occa- 
sionally seen presents a fibrinous deposit over isolated areas of the colon. 
Quite generally there is a swelling of the retroperitoneal and mesenteric 
glands. Bronchopneumonic patches are often found at necropsy. 

Symptomatology. — In a child whose vitality has already been im- 
paired by previous disease the attention may be directed to the condition 
of the stools, which are frequent and passed with much straining. These 
stools may contain blood-streaked mucus with undigested food masses. 
Fever is quite constant and varied in degree, in the beginning 102° to 
105° F. with a correspondingly rapid pulse rate. In the severer cases 
there is rapid prostration and vomiting. The stools are passed with 
tenesmus, and abdominal pain may be marked. There is restlessness, and 
often delirium, with intense thirst. The eyes are sunken and expressionless. 
The lips and tongue are dry and coated. The stools are now frequent — 
from ten to twenty a day — small, and contain almost no feces. Death 
will occur from exhaustion or a pneumonic complication if the symptoms 
do not show signs of abatement. Improvement is shown by a decrease in 
the number of stools, a lowered temperature with absence of vomiting and 



DISEASES OF THE DIGESTIVE TRACT. 193 

tenesmus. The lost vitality is regained very slowly. For days or weeks 
there is a low-grade temperature, and temporarily the tenesmus or green 
stools may appear. 

The appetite is capricious for a long time. The abdominal tone which 
is lost during the height of the disease will now slowly return to the norma 1 * 
and the child will gain in weight. 

Diagnosis. — The diagnosis is made from the presence of mucus and 
blood in diarrheal stools passed with straining over a period of several days 
or weeks in a child of deficient vitality. 

Intussusception is differentiated by the absence of fever, the acute 
onset, the pain, the shock, the presence only of mucus and blood, but no 
feces, and a tumor palpable through the abdomen or rectum. 

Course and Prognosis. — Severe types end fatally after a few days, 
or a week at most, of high fever and prostration. The mortality rate is 
from 30 to 40 per cent. The subacute types remain ill for a month or 
six weeks with periods of remission and relapses and a slow painful con- 
valescence. The prognosis is more favorable in this class, especially if 
they are removed to suitable surroundings, and have proper nursing and 
attendance. Infants withstand the disease badly. 

Treatment. — This does not differ from that given on page 188, under 
gastroenteritis. It should be recalled that these infections may be com- 
municated to others in a family or ward. An initial cleansing of the 
bowel with castor oil or calomel is imperative, followed by starvation for 
twelve to twenty-four hours. Egg albumin, barley water, or beef broth 
may be given (see p. 144). Equal parts of beef broth or barley gruel are 
sometimes more acceptable. Protein milk often produces happy results 
(see p. 145). 

The tenesmus is relieved by the control of the diet and by the use of 
codein gr. 4 to ^. according to the age, or Dover's powder, gr. \ to 2 
grains every two or three hours, until the painful symptoms abate. Sup- 
positories containing cocain gr. \ and aristol gr. 15 are soothing in older 
children. Bismuth subcarbonate gr. 20 or bismuth subgallate gr. 2. with 
powrlerorl ipecac gr. 1. may be given advantageously every two or three 
hours for the control of the mucus and blood in the stools in the later 
stages. 

After the acute symptoms have subsided sterilized milk is allowed in 
small amounts well diluted with barley or wheat-flour gruel. Later pas- 
teurized milk is permitted with jellied gruels and broths. The prostration 
may require hypodermatic medication in the form of atropin gr. 1/400 
with strychnin sulph. gr. 1/250. As a daily routine, one saline irrigation 
13 



194 DISEASES OF CHILDREN. 

at 100° F. serves a double purpose, as a cleansing solution and for absorp- 
tion of part of the water. Strychnin sulphate gr. 1/300 may be given as a 
tonic three times a day, and astringent enemas for the control of blood 
and mucus. Silver nitrate 2 per cent, or a starch paste in less severe cases 
may serve the latter purpose. They should not be given more than once 
daily, and discontinued if the effect is not satisfactory. Too frequent 
irrigations often cause irritation and aggravation of the symptoms. Be- 
moval to the seaside or cool mountain air is a great help in the management, 
particularly in the convalescent stage. 

Chronic Gastrointestinal Indigestion. 

This is a condition resulting from deficient motor and secretory powers in 
the alimentary tract, or as a result of continued improper food. 

Etiology. — Improper feeding, especially in poor children in the cities where 
the surroundings are unhygienic, is the principal cause of this affection. When 
the food is radically wrong, or unwholesome, an acute condition develops which 
makes the parent seek medical treatment ; on the other hand, the chronic con- 
dition due to incapacity to digest certain ingredients of the food is often over- 
looked or ascribed to anemia, parasites, etc. An excess of the fats, carbohy- 
drates, and sugars or of the proteins may overtax the intestinal digestion, thereby 
using up energy which should have produced development and growth. 

In older children badly prepared foods or indulgence in rich foods, pastries, 
and condiments lead to this condition. 

Pathology. — There are no definite organic changes found in this disease. 
If of long standing, the lymph follicles in the region of the ileocecal valve may 
be hypertrophied or a chronic colitis may be found. 

Symptomatology. — As indicated above, the symptoms are not appreciable 
at first, unless the disease directly follows an acute gastritis or enterocolitis. 
After some time failure to gain weight is noticed ; the child sleeps badly, has 
frequent attacks of colic, and cannot easily be comforted; the stools become 
diarrheal for several days, then resume a more normal appearance, only to relapse 
into a condition . f diarrhea or even constipation. Closer examination of the stools 
shows that they consist of masses of undigested food, intermingled with a small 
quantity of mucus, while streaks or splashes of green color are not infrequent. 

The musculature becomes soft and flabby. If the child has previously sat up 
or walked, it may now be unable to do so. The abdominal wall offers little or no 
resistance on palpation and the normal peristalsis is sluggish. The temperature 
is rarely elevated except late in the disease; on the other hand, a subnormal 
temperature is not uncommon. Intertrigo in the napkin region is exceedingly 
common in infants. If corrective measures have not been instituted by this time 
a marantic condition supervenes which may lead to a fatal issue. 

In older children the symptoms are not as marked, but the stationary weight 
or loss of weight, anemia, and listlessness should recall the possibility of this 
condition. The appetite is capricious, and as a consequence the children are 
indulged to a vicious degree by their parents. Attacks of constipation alternate 
with diarrhea, the urine is somewhat decreased in amount, it may be cloudy, and 
contains an excess of indican (see Plate I). The children become irritable and 
moody, having seemingly lost their former characteristics. They become cold 
easily, develop headaches, and are easily nauseated. The abdomen becomes 
prominent from gas distention, the stomach itself, if mapped out, shows enlarge- 
ment, but there is no pain or tenderness on abdominal palpation. 

Treatment.— Good hygiene and proper dietetic treatment are absolutely 
necessary to effect a cure. In the case of the poor, removal to a properly con- 
ducted hospital, preferably one near the seashore, will often work wonders. 



DISEASES OF THE DIGESTIVE TRACT. 



195 



The diet must be so adapted that it will correct the former faults, but still 
take into consideration the deficiency of digestive secretion and maldevelopment 
of the alimentary tract. An analysis of the breast milk or of the last formula 
given to an infant, studied in connection with its stools, will usually show which 
ingredient is at fault. A wet-nurse will sometimes quickly produce an ameliora- 
tion of the symptoms. Detailed instructions as to the room, air, bathing, and 
exercise must be given if the patient is to remain at home. The roof or piazza 
can be effectively utilized, and the greater part of the day should be spent out of 
doors. Before any dietary changes are made it is well to wash out the stomach, 
and thoroughly irrigate the bowels with saline solution. In some instances the 
bowel irrigations may have to be repeated once or twice. An initial dose of 
castor oil. one to two drams and a minim or two of the tincture of nux vomica, 
three times a day, will usually constitute all the drug treatment that is necessary. 

If the infant is artificially fed, the milk can for a time be so modified as to 
prevent the curdling action of rennet in the stomach by the use of peptonization 
or the alkalies or the addition of sodium citrate. A formula weaker than the 
requirements of a normal child of a corresponding age must be temporarily given. 
Rapid gain in weight must not be expected. Convalescence is slow and pro- 
tracted. 

The management in the case of older children is mainly dietetic. From time 
to time a diet list of certain permissible articles of food should be given, begin- 
ning with such as are easily digested and assimilated, and gradually increasing 
the number and variety as the improvement warrants (see diet list, p. 160). 

Aerotherapy, stimulating baths, and massage are necessary adjuncts to the 
dietetic treatment. Without constant supervision and attention to the daily 
routine, meager improvement will be experienced. 




Fig. 56. — Congenital dilatation and hypertrophy of 
colon. Transverse colon sagging into pelvis. 



Congenital Dilatation of the Colon. 

(HirscJi spni riffs; D isease. ) 
This is a rare condition which consists of an increase in the length and 
circumference of the descending colon and the sigmoid flexure. In some cases 
there is an added hypertrophy of the muscle fibers. As a result of this condition 
the abdomen is greatly distended from meteorism, feces are more or less retained, 
the constipation is extremely obstinate, and when the fecal masses are passed, 



196 DISEASES OE CHILDREN. 

either naturally or by artificial means, they are extremely foul, putrescent, and 
may be covered with mucus and some blood. 

Treatment. — Daily irrigations must be used to produce bowel evacuation. 
Massage and douching of the abdomen with cold water should be persisted in for 
a long time. Internally the daily administration of a laxative and drop doses 
of the tincture of nux vomica before meals are advisable. Since the condition 
predisposes to the ready putrefaction of food elements, owing to the stasis which 
results from meager peristaltic action, it is necessary to carefully supervise the 
diet, feeding only wholesome milk, well-cooked cereals (at least 3 hours), 
scraped meats, chicken, etc., and stewed fruits. Foods which may contain large 
quantities of purin bodies are especially to be avoided. If, in spite of the dietetic 
and mechanical treatment, the condition is not improved, surgical intervention 
may be considered — some surgeons electing to do plication. An X-ray exam- 
ination with a bismuth meal will give a good idea of the progress that is being 
made by treatment. 

Cholera Infantum. 

Cholera infantum is a very acute disease characterized by rapid pros- 
tration, vomiting, and a profuse serous diarrhea. 

Etiology. — It occurs almost entirely in the hot months of the year, 
among the poorer classes who live on inferior milk, and very rarely attacks 
breast-fed infants. It is the result of a toxic poisoning from an organism 
or group of organisms still undetermined. 

Symptomatology. — The symptoms are out of all proportion to the 
anatomical lesions which are found at necropsy. A child apparently quite 
well or only ill from a digestive disturbance suddenly begins to vomit and 
has a rise of temperature. A profuse diarrhea follows, possessing the char- 
acteristics of decomposition with very foul-smelling stools. The stomach 
and intestinal contents are at first expelled in this manner. The vomiting 
then consists of a watery fluid with flakes of mucus. The stools also now 
lose their fecal character, and are watery, greenish-gray in color, with a 
peculiar old musty odor which is quite characteristic. These discharges at 
first copious and explosive become smaller in amount but very frequent; 
they consist of serum and mucus, and may be as many as twenty or thirty 
a day. In some cases there is an almost constant oozing from the anal 
ring. The vomiting and diarrhea with the high temperature causes a 
quick collapse and an emaciation which is extremely rapid, due to the 
character of the discharge, which is largely blood serum. The extremities 
are cold, the pulse feeble, the respirations shallow and sighing, and the 
infant lies in a semicoma. Thirst is extreme, and water is eagerly taken. 
Meningitic symptoms supervene, with delirium, twitching, purposeless 
movements or convulsions. Unless the progress of the disease is arrested, 
the temperature rises to 105° or 107° F., with coma and death resulting 
from cardiac exhaustion at the end of the second or third day. If the 
treatment has been successful, the convalescence is extremely slow and 
demands incessant care. 



DISEASES OE THE DIGESTIVE TRACT. 197 

Course and Prognosis. — This should always be given as extremely 
bad. If prostration comes on rapidly, with high temperature and nervous 
symptoms, the course is often not longer than twenty-four hours. 

Treatment. — This must be energetic and heroic if any good is to be 
accomplished. Gastric lavage with warm saline solution should be made 
if the patient is seen early. If prostration is apparent, stimulation is the 
first indication, and is here best obtained by the use of hypodermoclysis 
which supplies the tissues with fluid and likewise stimulates. Inject eight 
to ten ounces into the subcutaneous tissue of the abdomen — using for this 
purpose sterile normal saline solution (6 grs. to the liter) and repeat this 
every four to six hours. Enemas of normal salt solution may also be 
employed. For a very rapid effect a hypodermatic injection of atropin gr. 
1/600 is efficacious, acting also as a check to the serous waste. This may 
be repeated every three hours if necessary. Camphor in sterile olive oil 
(one grain of camphor to every ten minims of oil) may be injected in the 
intervals, if the cardiac action is feeble. Immersion in warm baths at 
blood heat, or at 110° F. if the temperature should suddenly drop, is 
efficacious. They should be continued for a half-hour, and repeated at 
three-hour intervals ; gentle friction and the addition of mustard, one 
tablespoonful to the bath, will assist in keeping the extremities warm. No 
food is permitted and no medicines should be administered by mouth until 
the danger of death from collapse is past. Should the child rally, cautious 
feedings and medication as outlined under the article on Summer Diarrhea, 
is to be followed under the supervision of a competent nurse. As soon as 
possible thereafter a change to the seaside should be made. 

Constipation. 

This should be regarded as a symptom and not a disease, and accord- 
ingly the underlying cause should be sought for and corrected. 

Etiology. Rare Causes. — The condition may be caused by congenital 
anatomical abnormalities, by new growths, or by the disproportionate length 
of the sigmoid flexure. Adhesive peritonitis (especially the tuberculous 
variety) also causes constipation. 

The commoner causes are mainly dietetic. Artificially fed infants 
are the most frequent sufferers because of badly balanced food mixtures 
(see Artificial Feeding, p. 1-40), either too large or too small an amount of 
one ingredient of the milk, or the boiling of the milk itself acting as causes. 
Breast-fed infants are constipated from deficiency in the fat or total quan- 
tity of solid? present in the mother's milk. In older children a badly 
arranged dietary, especially a deficiency in the carbohydrates and fruit 



198 DISEASES OF CHILDREN. 

juices, will cause this symptom. Next to the diet, the lack of training of 
the child is an important cause in producing constipation. Children who 
suffer from constitutional diseases, such as rickets and infantile atrophy, 
may be constipated because of the lack of expulsive power and deficient 
peristaltic action. 

Other causes are deficiency of the intestinal and biliary secretions, 
nervous inhibition of the normal peristalsis in such diseases as meningitis, 
and intestinal parasites. The fear of causing pain when at stool, as from 
fissures of the anus, may lead to constipation. 

Symptomatology. In Infancy. — Colicky pains and flatulence precede 
the passage of the fecal mass, which is hard and dry or putty-like. Ab- 
sorption of the toxins may cause rise of temperature or possibly convulsions. 
These infants are inclined to be fretful with capricious appetites and are 
poor sleepers. They are likewise inclined to eczema. Eectal examination 
will reveal the fecal masses. 

In Older Children. — The tongue is coated, the breath is foul, and 
there is lassitude and depression with headache. There may be a slight 
rise of temperature, and the complexion becomes sallow or pasty. The 
appetite is lost. Sleep is disturbed. The stools are passed with an effort, 
may be mucus-coated and exceptionally large and ball-like. The child 
may go for several days without a movement. Digital examination will 
clear up any doubtful case. 

Treatment. — With persistent and patient effort all cases can be 
cured. The food taken by the child must be studied and the error 
which is usually dietetic set right. Medicines should have a minor place; 
the main reliance should be on diet, correct habits, and massage. 
Deficiency in the total amount or irregularity of any of the food com- 
ponents must be properly balanced. If the fats are deficient in 
the mother attempt should be made to improve the milk by dietetic and 
hygienic measures, and by regulating the amount of sleep and exercise. 
If this fails, alternate feedings or supplementary feedings of modi- 
fied milk may be given. Nursing mothers should be placed on a diet 
list which would include plenty of clean raw milk, cornmeal gruel, 
and water between meals. Feeble infants in whom the efforts to 
expel the mass are unsuccessful, as is evidenced by the finger in the rectum, 
are helped by gentle massage of the abdomen, the introduction of a gluten 
suppository or the nipple of a rectal syringe. Artificially fed babies are 
most often constipated because they are usually on a modified food incorrectly 
ordered. See to it that there is a sufficiency of fat and protein in the mix- 
ture and that the curd is mechanically broken up by the addition of a gruel. 



DISEASES OF THE DIGESTIVE TRACT. 



199 



Oatmeal gruel may be tried in infants suffering from constipation. Water 
between the feedings must be offered freely. A tablespoonful or two of 
orange or pineapple juice is decidedly beneficial in infants after the first six 
months of life. Beef juice or chicken broth are laxative and may be 
judiciously employed. If the mixture has been made up with a pro- 
prietary infant food, this should be changed. If the constipation has 
been neglected for some time it may be necessary to use soap enemata, 
four to eight ounces at a time. Glycerin suppositories at first may be 
tried in conjunction with a proper diet and hygienic measures, and then 
gradually use milder procedures as improvement takes 
place. By simpler procedures is meant the injection of 
a few drams of olive oil or an ounce of warm water with 
a baby rectal syringe. 

The elixir of cascara sagrada (N\ F.) ten to thirty 
drops may be prescribed, or malt and cascara given in 
the minimum dosage possible to produce a satisfactory 
movement (one-half to one teaspoonful). As soon as 
the supplementary measures can be depended upon, the 
medicines should be abandoned altogether. 

A regular stooling habit can be cultivated almost 
from infancy by placing the baby on a small commode 
at regular intervals and is a prophylactic measure of 
importance in child life. 

The constipation of older children may be corrected 
by the addition of cream and butter to the food, or in 
other instances, a greater amount of vegetables and fruit 
The giving of food stuffs that leave a large residue in 
the bowel are of service, such as bran biscuit, shredded wheat biscuit, whole 
wheat bread, graham crackers, agar-agar (the latter to be mixed in about 
1 teaspoonful) with the morning cereal. (See special diets, p. 163.) Tak- 
ing a glass of water on arising, followed by a cold sponging and abdominal 
massage will cure many cases if regularly carried out, besides improving 
the general body tone and blood-supply. Calomel, castor oil or the salts 
should not be given for this condition. They are cathartic in action and 
tend to produce constipation. 




Fig. r>7.— Rectal 
syringe for infants. 

must be ordered. 



Amebic Dysentery. 

Etiology. — Sporadic cases of amebic dysentery in children have come under 
our observation with greater frequency in the past few years. The diarrhea is 
characterized by profuse, watery stools admixed with blood from which the 
ameba coli can be isolated. It probably occurs much more frequently than is 
recognized in our Southern States, and because of our colonial possessions it is 



200 DISEASES OF CHILDREN. 

more apt to gain an entrance into this country. The exact sources of infection 
are not known but in all probability the intestinal tract is infected by contami- 
nated drinking water or the ingestion of raw vegetables or fruits. 

The ameba is a unicellular bit of motile protoplasm haying a clear outer 
zone and an inner granular area with a nucleus and usually some vacuoles are 
present. Schaudin describes two varieties — Entameba coloid, a nonpathogenic 
organism, and Entameba hystolytica, a pathogenic organism. Later observers 
have pointed out that all forms may become pathogenic. The United States 
government refuses admission to the Hawaiian Islands of any Filipino whose 
stools contain ameba of any kind. 

Examination of Stools. — The specimen is collected on a warm glass slide, 
from a freshly passed stool. If the stools are not free, a saline laxative may be 
given. The mucus present or a shred of mucous membrane usually contain the 
greatest number of ameba. Leischmann's stain may be used. 

Pathology. — The lesions consist of ulcerations in the large intestines or the 
lower part of the ileum. Necrosis of the mucous membrane over these ulcers soon 
takes place leaving a dirty edematous, submucous layer exposed. The ulcers are 
generally undermined with rounded infiltrated edges. In aggravated cases the 
muscular or even the serous coat may be exposed and the ulcers are then found 
extending through the hepatic flexure into the rectum. 

Symptomatology. — An irregular diarrhea in a child which does not abate 
after the usual course of treatment should excite our suspicions and invite careful 
examinations of the stools for the presence of the ameba. This is especially true 
if sudden exacerbations occur after a period of apparent quiescence. The 
stools are usually very numerous, watery and contain mucus and blood. The 
blood varies in quantity and is out of proportion to the amount of mucus. During 
the exacerbations in which the patient will have abdominal pain and tenesmus, 
the ameba are more likely to be found in the fresh stool. The course of the 
disease is rather protracted and convalescence is slow, usually complicated by a 
secondary anemia. We have never observed complicating abscesses of the liver 
or lungs in any of our cases, although these form most dangerous sequella? in 
tropical countries. The ameba are persistently found in the stools even after 
convalescence is well established and the stools are no longer dysenteric in 
character. 

Treatment. Prophylactic. — Contaminated food and water convey the dis- 
ease, the latter in turn, being infected probably through the agency of the common 
fly. For the most part it may be regarded as a water born disease, boiling the 
water and even the milk is necessary in suspected localities and tropical countries. 
No raw vegetables should be included in the dietary of children residing in locali- 
ties where the disease is endemic. The patient should be kept in bed at rest until 
the stools assume a formed character. This is necessary to prevent exacerba- 
tions and complications. The diet should consist of warm gruels or paps 
made from such articles as arrowroot, cornstarch or farina. It is best to 
withhold milk until the active symptoms have subsided. Eggs and thickened 
broths may be cautiously added, and finally whey and milk. 

Drug Treatment. — One-half to one ounce of castor oil should be given at 
the outset. Bichloride of mercury in doses of 1-80 gr. in sol. may be given every 
two hours, until the stools regain their normal characteristics. The abdominal 
pain is relieved by hot turpentine stoops, and the tenesmus with thin starch 
enemata. Warm colonic irrigations of quinine in solution 1 to 1000 are destructive 
to the ameba. The syrup of the iodide of iron is indicated in convalescence as it 
counteracts the anemia. Change of climate should be ordered if possible and the 
attendants instructed to carry out typhoid precautions until the stools are entirely 
free of the infecting agent. 



CHAPTER XIX. 

THE ANIMAL PARASITES. 

These ma}' be conveniently divided into several groups and sub-groups 
(see table below). Only those that are found with some frequency in 
childhood will be described and pictured. 

Parasitic Protozoa. 

Animal Parasites Found in Childhood: 

Nematodes. — Oxyiiris vermicularis (thread worm). Ascaris lumbri- 
coides (round worm). Trichina spiralis. Ankylostoma americana (hook 
worm). 

Cestodes. — Tenia saginata. Tenia solium (pork tape-worm). Both- 
riocephalus latus. 

Although infection is more frequent with intestinal parasites among 
children than in adults, the cases are mainly found in the offspring of 
foreigners in this country. 

These parasites are taken to be the cause of many of the ailments of 
children by parents frequenting the dispensaries and many of them have 
been given the therapeutic test without any clinical evidence of the parasites 
being present. "When they are present in any quantities they may do harm, 
especially in sickly children, by impoverishing the albumin content, by 
acting as foreign bodies in unusual sites, and by poisoning their host through 
their metabolic products. The evil effect of intestinal parasites is often 
exaggerated in the mother's mind. 

Oxyuris Vermicularis. 

(Thread Worms.) 

These are small white filament-like worms usually found in the rectum. 
The female is larger than the male, and usually is found in the cecum, 
until impregnated, when it descends to the rectum. 

The eggs are oval, asymmetrical, about 0.05 mm. in size. Their inte- 
rior is filled with a granular yolk, containing a clear nucleus. The oxyuris 
differs from some of the other parasites in that it does not require an 
intermediary host. The worms and the eggs pass out of the rectum alone 
or with the feces, and may directly inoculate a human body. The child 
may reinfect itself by handling toys, or food, and may infect its playmates. 
The ova are carried in drinking water or by flies to vegetables and fruits. 

201 



202 



DISEASES OE CHILDREN. 



Symptomatology. — The worms by their presence may produce 
irritation of the anus, or if present in sufficient numbers, even a colitis 
or proctitis may result. The children sleep poorly and scratch about 

the anus. They lose their appetites, be- 
come irritable, and even anemic. In girls, 
particularly, the parasites may invade the 
genitals, and result in masturbation or in- 
continence of urine. Sometimes no symp- 
toms are to be noted. 

Diagnosis. — An enema of cold water 
will disclose any parasites present if they 
are not found in the stools or at the anus. 
The eggs are found with difficulty in the 
stools; more often they are found under 
the finger-nails of the infected child. 

Treatment. Prophylactic. By at- 
tention to the person of the patient, self- 
inoculation can and must be prevented. 
Baths, clean finger-nails, restrictive ap- 
paratus for the hands or heavy canvas 
drawers to prevent scratching are some- 
times necessary. Examine other suscep- 
tible members of the family to prevent 
reinfection. 

Internal. — A grain of calomel or a tea- 
spoonful of Rochelle salts in water is given 
to bring down the females from the cecum. 

Locally. — Daily enemata of saline 

solution may be given followed three 

times a week by injections of the infusion 

of quassia, this to be retained for a time 

if possible. Further, a 2 per cent, yellow 

oxid of mercury ointment is applied about and into the rectum at night. 

This treatment should be persisted in until the bowel is thoroughly rid 

of the worms, and renewed if any are seen at a later date. 




Fig. 58. — Oxyuris vermicula- 
ris ; a, sexually mature female ; 
J), female with eggs; c, male. 
(After Heller.) 



Ascaris Lumbricoides. 

(Round Worm.) 
This parasite is round with a smooth body from four to six inches 
long and pointed at each end. The mouth has three suckers and teeth. 



THE ANIMAL PARASITES. 



203 




Fig. 59. — Ascaris lumbricoides. 
6, cephalic end enlarged, showing 
A, a female ; B. a male natural size; 
lips. (After Peris.) 



The female is very prolific, producing 
millions of eggs. These are rounded 
or oval in shape (see Fig. 59). It has 
been proven by experimentation that no 
intermediary host is necessary. Al- 
though they normally inhabit the 
small intestine, they move from place 
to place. They have been frequently 
vomited from the stomach and have 
been found in the gall bladder and 
appendix in children. Through its 
ova it gains entrance to the human in- 
testinal canal. Bound worms are 
spread by water and uncooked vege- 
tables through deposited ova. 

Symptomatology. — The parents 
themselves often make the diagnosis of 
round worms when they have seen 
them passed. "When questioned the 
majority of the patients do not give 
any symptoms directly referable to the 
worms, and many have had no symp- 
toms whatever. The symptoms usually 
present are loss of appetite, nausea, or 
diarrhea, occasionally there are pains 
referable to the abdomen, which are 
soon forgotten, only to reappear again. 
Pruritus ani, pavor nocturnus, chorei- 
form movements, and convulsions have 
been observed. A rather constant 
eosinophilia is present in patients with 
round worms, and this should be a stim- 
ulus to examine the feces for ova. By 
their local action of migration they may 
produce obstruction of the intestine 
or even a fatal issue, as in laryngeal 
obstruction. 

Diagnosis. — The microscopic ex- 
amination for the ova is readily made 
and should not be omitted in ques- 
tionable cases having an eosinophilia. 



204 



DISEASES OF CHILDREN. 



Treatment. Prophylactic. — Cleanliness of body, a pure water-supply, 
and avoidance of unboiled vegetables for children decrease the possibility of 
infection. Care in the handling of the stools of children will also prevent 
infection of others. 

Internal. — Calomel and santonin is a dependable combination for this 
parasite. A half -grain of each drug with sugar of milk is usually sufficient. 
Never give more than a grain of santonin, as poisoning may be produced. It 
is best given with some food and in divided doses. The stools should be 
examined for ova each week for three weeks, as until then there is no posi- 
tive certainty of their absence. 

Cestodes, or Tape-worms* 

General Characteristics. — The tape-worms commonly met with in 

this country in children are the Tenia mediocanellata (er saginata) or beef 

tape-worm, and the Tenia solium or the pork tape-worm. They are flat, 

ribbon-like, jointed parasites, yellowish in color, and vary in length from 




Fig. 60. — Head of Tenia 
saginata, much magnified. 




Fig. 61. — Head of Tenia 
solium. showing scolex, 
suckers, hooks, and neck. 



ten to twenty feet, the segments growing smaller until the head is reached. 
It is only in the intestinal tract of man that the fully developed parasite is 
found. The ova are taken into the alimentary tract of an animal and their 
covering is dissolved and they then pass through into the muscles of the ani- 
mal and become encysted there. Such meat is commonly spoken of as being 
"measly." This infected meat when eaten by man allows the larvag to 
develop into the tape-worm. Although occurring rarely, man may himself 
act as the intermediary host and cysticerci develop in his organs. 



THE ANIMAL PARASITES. 



205 



Tenia Mediocanellata or Saginata (The Beef Tape-worm). 
These worms may be distinguished by the appearance of their 
heads under the magnifying glass. The head of the beef worm is 
cuboid, slightly darker than the rest of the body and it has no hooks 

as the pork worm has; instead four suckers 
are seen on the head. Its eggs are smaller 
than that of the Tenia solium, and contain 
hooklets. 





Tenia Solium (The Pork Tape-worm or 
the Armed Tape-worm). 

The head of this parasite which is about 

ffj the size of a pin-head, has besides the four 
^ I suckers found on the beef-worm, a set of 

1 I hooklets. They often reach nine feet in 

- length. The eggs are round and contain 

the embryo with its hooklets. 

Symptomatology. — In the great ma- 
jority of cases there are no pathognomonic 
symptoms referable to the tenia?. Often it 
is only when the segments are passed that 
their presence is indicated. Older children 
may complain of grumbling, griping pains, 
and have symptoms of indigestion. They 
become anemic, have headaches, and com- 
plain of dizziness. Sometimes a capricious 
or voracious appetite may excite suspicion, if 
coupled with a history of eating raw beef 
or pork. 

Treatment. Prophylactic. — Proper 
meat inspection at the abbatoir. A dis- 
semination of the harm that may be caused 
by eating of raw or badly cooked meats 
and destruction by fire of all segments 
passed would materially reduce the number 
of these cases. The children of foreigners 
are especially to be warned. 
Internal. — The parasites can be removed if a systematic cure is out- 
lined and rigidly followed, as the head is firmly attached and must be dis- 
lodged to effect a cure. First dav: a dose of castor oil, at least a half 




Fig. 62. — Portions of a Tenia 
Saginata. (After Lpuckart, 
natural size.) 



206 



DISEASES OF CHILDREN. 



ounce, is given, followed by fasting for the remainder of the day. Second 
day : following a cup of clear consomme or weak tea, give the following 
prescription for a five-year-old child, while the child is kept in bed. 

P* 

Oleoresinse aspidii 3j 

Mucilaginis acaciae 3ij 

Spiriti chloroformi nix 

Aquae cinnamomi q.s. ad. Bj 

Misce et Sig. — One-half the quantity at a dose. 

The remainder is given after a few hours, if the child should vomit 
the first dose; they rarely reject the second, if kept prone in bed. 

Several hours after the vermifuge has been 
given, a glass of the effervescent citrate of magnesia 
is taken. The worm should be passed into a clean 
vessel, containing warm water, and careful examina- 
tion made for the head, for unless this is identified, 
the cure will be unsuccessful. 

This treatment has been so successful in our 
hands, that there has been no necessity to resort to 
less reliable vermifuges, as the pelleterine tannate, 
kousso, kamala, etc. 

Hymen-O-Lepis-Nana. 

(Dwarf Tape-worm.) 
The habitat of this tape-worm is in the upper 
two-thirds of ileum. It presents no special symp- 
toms. Its average length is 14 to 16 mm. The seg- 
ments are three to six times as broad as long. The 
head is globular and carries four segments. 

Uncinaria Duodenalis. 

(Ankylostomum Duodenale or Ho oh Worm.) 
This parasite has assumed a greater interest for 
us in the past few years because of our new posses- 
sions in the West Indies, and since the publication of the investigations of 
Stiles who has shown how prevalent they are in the children of the Southern 

States. 

The hook worms are small thread-like parasites with four teeth which 
enable it to attach itself to the intestine, the jejunum being its favorite 
site. The eggs develop rapidly and the embryos are very tenacious of life. 
The eggs are oval in shape, with a distinct capsule and a brownish content. 




Fig. 63. — Uncina- 
ria duodenalis. (Af- 
ter Loss, X 105.) 



THE AXIMAL PARASITES. 



207 



Unclean water, the eating of raw vegetables, and unclean hands and bare 
feet are the means through which infection takes place. 

Symptomatology. — The children having hook worms are pasty, white 
and thin. The appetite is abnormal; mainly a craving for the unusual. 
The anemia is marked, so that the patient is listless, without ambition, and 
mentally dull. Later the abdomen becomes prominent and there is edema 
of the extremities. The stools if examined show the ova. 




! \yy 




—oe- 




Fig. 64.- — Oral capsule of Uncinaria duodenalis. 



Treatment. — Thymol is almost a specific for the hook worm. The 
bowels should be emptied with calomel or castor oil, the diet restricted, 
and thymol given in five-grain doses every two to three hours until twenty 
grains of the solid drug are taken. Another purge should now be admin- 
istered or a high enema given. Weekly examinations of the stools should 
be made, and if any are found, repeat the cure each week. Following the 
elimination of the ova, an iron peptonate should be prescribed until the 
hemoglobin content is normal. 



Trichina Spiralis. 

Children are liable to infection from this parasite by eating diseased pork. 
Those living in country districts where the curing of the pork is done at the 
farmer's home are especially liable. The encapsulated trichinae are freed in the 
stomach, propagate and deposit living embryos. Those which are not passed out 
of the intestinal canal, reach the muscles where they develop and finally become 
encapsulated. 

Symptomatology. — During the first week of their ingestion the symptoms 
are slight and those of a gastrointestinal nature. Then general muscular pains 
with high fever develop and are often mistaken for rheumatism or typhoid. 
Transitory swellings appear. The muscles are painful to the touch; nausea and 
vomiting or diarrhea may lie present. Dysphagia prohibits the taking of nourish- 
ment. Stupor and coma may ensue in fatal cases. Eosinophilia is marked and 
is a distinct aid to the diagnosis. 

Treatment. Prophylactic. — Reliable meat inspection and thorough cooking 
of all hog meat (200° F. are necessary to kill encapsulated trichinae) are measures 



208 



DISEASES OF CHILDREN. 



of prophylaxis which are self evident. Better still, pork in any form should be 
prohibited in the dietary of the child. 

Internal. — Calomel is given until free purgation is obtained. Benzol is then 
administered in grain doses, alternating with glycerin half a dram every four 
hours. Good nursing is necessary to keep up the strength of the patient through 
long convalescence. 



ry9. 




Fig. 65. — Encapsulated muscle trichina. (After Leuckart.) 



PLATE V. 




Ova of the cestodes of early life. Tenia solium (Pork tape-worm), p-p'; Tenia 
saginata (Beef tape- worm), q-q' ; Bothriocephalus latus (Fish tape-worm), k-k'; 
Uncinaria americana (Hook-worm), x-x'-x"-x"'; Ascaris lumbricoides (Round- 
worm), y-y"; Oxyuris vermicularis (Thread-worm), d-d'-d"-d'". 



CHAPTER XX. 
DISEASES OF THE LIVER. 

The Liver. 

The liver is of relatively large size and functional importance in early 
life. In fetal life it is a very important factor in the circulatory system, 
while the lungs are largely inactive. Thus in the mature fetus the liver 
holds a quarter or more of the entire volume of blood, and it is greater in 
size than both lungs. As the lungs of the fetus are solid, and almost im- 
pervious, the placenta of the mother performs the double function of a 
respiratory and of a nutritive organ. After the venous blood is received 
from the fetus it must be returned reoxygenated, and nearly the whole of 
this purified stream is carried to the liver by the umbilical vein and circu- 
lates through this organ before reaching the vena cava and the general 
circulation. The large size and importance of the liver in fetal life are 
thus understood by considering it a sort of intermediary organ between the 
placenta and the general circulation, as far as the reoxygenated blood is 
concerned. At birth the lungs should at once innate and assume the 
respiratory function. The umbilical vein is completely obliterated in a few 
days and finally becomes the round ligament of the liver and the ductus 
venosus is likewise obliterated. Although the liver now loses its preponder- 
ating importance in the economy, it still remains relatively larger and 
heavier than in later life. The diminution of the organ is due to its altered 
blood supply, and is especially marked in the left lobe. The loss of weight 
that begins at birth continues, so that there is a direct ratio from infancy 
to old age in this relative diminution. In infancy the liver weight is in 
proportion to the whole body as one to twenty: at puberty, one to thirty; 
in adult life, one to thirty-five; in middle life, one to forty; in old age. one 
to forty-five. 

Examination of the Liver. 

The child is placed in the recumbent position with the thighs flexed 
in order to relax the abdominal muscles as much as possible. The organ 
may then be mapped out by palpation and percussion. The liver projects 
from -| inch to 1 inch below the free borders of the ribs. In the median line 
the lower border of the left lobe extends to within about an inch of the um- 
bilicus. It must be borne in mind that the liver ascends and descends with 

200 
14 



210 DISEASES OF CHILDREN. 

full inspiration and expiration. If the organ is enlarged it can be detected 
by deep palpation and effort should be made to map out the seat and 
character of the swelling. 

On percussion, liver dullness along the upper border will begin at the 
right sternal margin and in the mammary line in the fifth intercostal space, 
in the axillary line at the seventh rib, and in the s-apular region at the 
ninth rib. Upon very light percussion, the dullness will be noted a little 
below these lines. 

Apparent enlargement of the liver may be caused by a slight displace- 
ment induced by the bony deformity of the thorax in rickets, by effusion in 
the right pleural cavity, by tumor of the right kidney, by fluid in the ab- 
dominal cavity, or by subphrenic abscess. The commonest causes of true 
enlargement of the liver in early life are abscess, fatty degeneration, 
cirrhosis, and leukemia. 

Jaundice. 

Icterus neonatorum has been considered in the section on Diseases of 
the Newly-born. In attacking infants some time after birth jaundice is due 
to causes similar to those found in children and adults. Owing to some 
obstruction in the biliary canals, the bile instead of passing into the intes- 
tine, is absorbed into the blood. 

An inflammation of the duodenum, accompanied by swelling of the 
mucous membrane at the opening of the ductus communis choledochus, may 
be responsible for this obstruction. The inflammation may also extend by 
direct continuity from the duodenum to the ductus communis and hepatic 
ducts, and thus cause retention of bile in the liver. 

A plug of inspissated bile in the common duct, and, more rarely, gall- 
stones may also cause obstruction. Complete stoppage has been reported by 
a round worm penetrating the common duct from the duodenum. 

Inflammatory changes in the liver, as in cirrhosis, may induce jaundice 
by obstruction from pressure in the intrahepatic ducts. Finally, certain 
toxic conditions, as in paludism and various infectious diseases, and rarely 
phosphorus poisoning may act as causes. 

Symptomatology. — . The most objective sign is the general yellowness 
of the skin and the conjunctiva?. Other abnormal tints of the skin simu- 
lating jaundice may be differentiated by the yellow conjunctivae and by the 
presence of biliary pigment in the urine. 

Itching of the skin may be present. Urticaria, which is so common in 
children, sometimes ensues when the papules and wheals will present a deep- 
yellow tint. The yellowness of the skin is usually only to be noted in a 
natural light. 



DISEASES OF THE LIVER. 211 

The most marked internal symptoms may be those that can be referred 
to a duodenitis or a gastroditodenitis. In the latter case there is more or 
less nausea and vomiting, with pain in the epigastrium, especially upon the 
ingestion of food and tenderness upon pressure in this region. 

There may be a subacute duodenitis without gastritis being present, 
when pain will be noted some hours after taking food as it passes from the 
stomach into the duodenum. The stools may be clay colored from an excess 
of undigested fat when no bile reaches the intestine. When the obstruction 
to the passage of bile is only partial the stools may retain a natural browish- 
yellow color. The complete absence of bile will be shown by a quick de- 
composition of the intestinal contents as exhibited in the free formation of 
gases and a foul odor of the feces. 

The pulse may be slow as the biliary salts have a sedative effect on the 
circulation. Most cases of jaundice in young children disappear in a few 
weeks without leaving any serious consequences, but rarely there may 
suddenly ensue evidences of blood-poisoning, followed by death. Occasion- 
ally the jaundice will last for months without giving rise to much apparent 
disturbance except a slight stupidity. 

Treatment. — Where there is no evidence of gastroduodenal inflamma- 
tion, active peristaltic action in the duodenum to be transmitted to the bile 
ducts may be induced by calomel, rhubarb, or colocynth. This may be 
followed by a mixture containing tincture nucis vomicae with bicarbonate 
of potassium or sodium, as alkalies are supposed to have a liquifying effect 
upon the bile, thus freeing the ducts when they are occluded by a thickening 
of this secretion. 

Only bland and easily-digested food must be allowed. All fatty foods 
must be restricted and the patient kept on lean meat and plain vegetable 
food. 

When the jaundice depends on a subacute inflammation of the stomach 
and duodenum, the saline laxatives and mineral waters do well. Carlsbad, 
Vichy, and Congress waters usually are beneficial. Persistent constipation 
is one of the commonest symptoms, and must always be relieved. 

Inflammation of the Biliary Ducts. 

An ordinary acute inflammation of the biliary ducts usually undergoes resolu- 
tion in a few weeks without any bad results being left behind. As a result of the 
inflammation a r-olleetion of mucus, often taking the form of a firm plug, is 
located at the opening of the common duct into the duodenum, thus causing 
more or less complete obstruction. 

In chronic cases there may result a thickening of the ducts, with dilation 
in places caused by the obstructed secretions. Rarely, ulceration may take place 
In the walls of the ducts. The mucous membrane of the gall-bladder may likewise 
be the seat of inflammatory changes. 



212 DISEASES OE CHILDREN". 

Symptomatology. — Various digestive disturbances shown by coated tongue, 
nausea or vomiting, and other symptoms pointing to a mild inflammation of the 
stomach are present at the start. There may be slight fever. 

In a few days the conjunctivae become yellow, the urine is colored by biliary 
pigment, and the feces assume a clay-like appearance. There may be a slight 
enlargement of the liver and the gall-bladder may be palpated. There may be 
some tenderness on pressure over the right hypochondrium. When the inflamma- 
tion of the ducts is secondary to congestion of the liver, there is less digestive 
disturbance and milder jaundice of shorter duration. 

The treatment is the same as that of jaundice. Where the inflammation is 
induced by changes in the parenchyma of the liver or by certain infectious dis- 
eases, treatment must be aimed at the underlying cause. 

Inflammation of the Portal Vein. 

Suppurative pylephlebitis may occur as a secondary lesion resulting frcm 
suppuration in some of the organs drained by the portal vein or its radicals. 
Ulcerations of the gastrointestinal mucous membrane, inflammation or ulceration 
of the biliary duct and umbilical phlebitis in new-born infants whose mothers 
are septic may spread to the portal system and set up inflammation there. 

Symptomatology. — Local pain in that part of the portal vein involved will 
follow the symptoms of the primary morbid condition. Enlargement and tender- 
ness of the liver may be due to a general hepatitis or to abscesses. The spleen 
may likewise become enlarged and tender from occlusion of the splenic vein. As 
pus forms in the portal vein, there will be chills, fever, sweating, and general 
emaciation. Intestinal indigestion with bilious stools and jaundice usually are 
present. Although there may be remissions, the disease usually ends fatally in 
a few weeks. 

Treatment. — All that can be done is to treat symptoms as they arise and 
sustain the strength as much as possible. 

Organic diseases of the liver are rare in early life and do not differ essen- 
tially from adult life. 

Congestion of the Liver. 

This condition may be active or secondary. The active form occurs during 
certain infectious diseases, especially paludism, and in the early stages of abscess 
of the liver. The secondary form is seen in affections of the heart and any other 
physical condition which causes stagnation in the liver by checking the access of 
blood to the ascending vena cava. 

The organ is enlarged in both forms, but more so in the cases of passive 
hyperemia. There is usually tenderness on pressure over the region of the liver. 

The treatment must be addressed to the disease or local conditfon that causes 
the congestion. Phosphate of sodium, citrate of magnesium, and other saline 
purgatives may be given to try and deplete the portal circulation. 

Fatty Liver. 

This condition may be present in various constitutional diseases, especially 
rickets and tuberculosis. It is more often secondary to the latter disease than to 
any other. Chronic intestinal disorders and blood dyscrasias may also act as 
causes. 

The organ is generally uniformly enlarged. In some cases the increase in 
size is very great, but tenderness is absent. There are usually no symptoms, and 
treatment of the original disease is all that can be accomplished. If there is 
little enlargement, the condition cannot be recognized during life, but it is seen 
to some extent in a large number of the autopsies made on young children. 

Amyloid Liver. 
Waxy liver is secondary to prolonged suppuration in any organ, to chronic 
joint or bone disease, to tuberculosis or syphilis. The liver is generally enlarged, 
with a hard, rounded border and free from pain on pressure. On section, it gives 



DISEASES OF THE LIVER. 



213 



a reddish-brown reaction with iodin. Similar changes also usually develop in the 
spleen and kidneys, and the spleen is thus enlarged. There are no distinctive 
liver symptoms or jaundice. Albuminuria may be present from the kidney 
affection, and ascites or edema from pressure. Gastrointestinal irritation, shown 
by vomiting and the passage of foul-smelling stools, is often noted. When waxy 
liver is recognized, it means some form cf chronic disease and a grave prognosis. 

The treatment consists in trying to> 
check the original focus of suppuration, 
in supporting the patient, and in handling 
various symptoms as they arise. 



Cirrhosis of the Liver. 

This disease is rare in early life and 
is oftener accompanied by enlargement 
than contraction of the liver. The com- 
monest primary causes are syphilis, alco- 
hol, and chronic paludism. Syphilitic 
cirrhosis is seen in early infancy, and is 
perhaps the commonest form of organic 
disease of the liver at this time. When 
alcohol acts as a cause, it is in older 
children of from ten to fifteen years of 
age. In chronic malarial poisoning, there 
is great enlargement of the liver when 
this organ is the seat of cirrhosis. There 
may be secondary cirrhosis, as in adults, 
from hepatic hyperemia due to chronic 
cardiac disease, from prolonged obstruc- 
tion of the bile ducts, and possibly from 
infectious diseases, such as measles and 
scarlatina. 

The pathology and symptoms do not 
differ from cirrhosis seen in later life. 
It is often difficult to recognize the dis- 
ease apart from the general condition, such 
as syphilis, that produces it. There may 
be no symptoms directly referable to 
the liver. Icterus may or may not be 
present, but enlarged spleen and ascites 
are common. 

The treatment must be directed to the 
primary disease and various symptoms as 
they arise. 




Ftg. 66. — Cirrhosis, hyper- 
trophic due to alcohol given 
from the time of weaning. 



Abscess of the Liver. 

Abscess may follow suppuration within the abdomen, very rarely from the 
migration of round worms through the common duct, from infectious diseases, 
and in the newly-born from sepsis. It is very rare, however, and the symptoms 
are similar to those seen in the adult. The treatment is surgical. 

Acute yellow atrophy and gall-stones occur with very great rarity in early 
life, and do not" differ in course and symptoms from the same affections in the 
adult. 



SECTION VI. 
THE INFECTIOUS DISEASES. 



CHAPTER XXI. 
THE EXANTHEMATA. 

The exanthemata consist of five diseases : scarlet fever, measles, German 
measles, small-pox and chicken-pox. All except small-pox are distinctively 
diseases of childhood; although any of them may occur in adults. Each 
runs a definite self-limited course, subject to variations and complications. 
As a rule, each renders an individual immune to future attacks of the 
same disease, but one does not confer immunity from another. Two of 
them may occur in the same individual at the same time. Each is divided 
into four stages : the stage of incubation, prodromal stage, efflorescence, and 
desquamation. 

The stage of incubation comprises the interval from the time when 
the contagium is taken into the system until the first symptoms appear. 
The prodromal stage is the period included between the appearance of the 
first symptoms and the appearance of the eruption. The stage of efflorescence 
extends from the time of the first appearance of the eruption until it fades 
and the stage of desquamation begins. As the great majority of cases run 
a typical course, such a form of the disease will first be described, always 
bearing in mind that the many variations and complications which are 
later described may alter the general picture. 

Measles. 

(Rubeola, Morhilli.) 

Definition. — Measles is an acute contagious disease characterized by 
a period of incubation, a prodromal stage with fever, coryza, lacrimation, 
cough, and Koplik's spots, followed by a red, papular eruption and a fine 
desquamation. 

Etiology. — Xo specific microorganism has as yet been discovered. 
The contagium is contained in the nasal, lacrimal, and bronchial secretions. 
It has been transmitted through direct inoculation of the nasal secretions 
and blood. It is, therefore, more contagious in the early stage. The con- 
tagion may extend through the eruptive and desquamative stages. It has 

214 



PLATE VI 




Measles, showing typical eruption. 



THE EXANTHEMATA. 215 

not the property of clinging tenaciously to such objects as clothing, and it 
is doubtful if it is often carried by a third person; surely not as easily 
as scarlet fever. Epidemics spread rapidly, owing to its transmission on 
short exposure and to its highly contagious character before the diagnostic 
eruption appears. Most people have the disease at some time during life; 
therefore, adults are not immune unless they have already had it. It is most 
frequent between the first and sixth years ; rare before the fifth month, and 
only 5 per cent, of the cases occur under one year. We have, however, seen 
it at birth. One attack usually protects the individual from further attacks, 
but recurrences are more common than in any of the other exanthemata. It 
occurs in all countries and at all seasons. 

Pathology. — The skin shows an infiltration of round cells which sur- 
rounds the sweat and sebacious glands as well as the capillary blood-vessels 
which are found distended with blood. The mucous membranes show in- 
flammatory changes. Other pathological conditions, such as bronchopneu- 
monia, are not typical of measles. 

Incubation. — Eight to twelve days ; usually ten days. 

Prodromal Stage. — Three to five days ; generally four days. The 
onset is not usually as abrupt as in scarlet fever. The child appears to 
have a cold in the head, has some cough, and a temperature of 100° F. to 
104° F.. according to the severity of the disease. There is not apt to be 
vomiting, nor are convulsions common, although either may occur. The 
corvza gradually increases, lacrimation and the nasal discharge become 
more profuse, the child grows sicker, and finally the face assumes the puffy 
appearance with redness about the nose and eyes commonly seen in a severe 
corvza. Very often a deceptive fall in temperature, with seeming improve- 
ment of the child's general condition, takes place on the second day, only 
to be followed the next day by a further rise of temperature and increased 
symptoms, which continue to increase until the eruption is at its height. 
There may l>e in some cases a regular remittent fever during the three or 
four days of the invasion. Koplik's spots, which are pathognomonic of 
measles, and almost invariably present, are found on the mucous membrane 
of the cheeks and lips all through the prodromal stage if inspected in strong 
sunlight. The first day there are usually less than six of these rose-red 
spots scattered over the pink mucous membrane, in the centre of which are 
bluish-white specks. Some are minute, about one-eighth of an inch in 
diameter. Soon they may increase in number until they coalesce and lose 
their characteristic appearance as the exanthem comes to its height. Kop- 
lik's spots are to be differentiated from the rose-colored papules with super- 
imposed whitish vesicles seen on the soft and hard palate in German 



216 DISEASES OF CHILDREN. 

measles, scarlet fever, and simple angina, as well as in measles. A redness 
of the fauces and pharynx somewhat corresponding to the characteristic 
eruption on the skin may be seen. 

Eruption. — On the third or fourth day the exanthem appears on the 
face in the form of discrete, raised, red, pin-head-sized papules. Thev are 
sometimes arranged in crescents. The eruption spreads to the neck, chest, 
back, and arms, and within thirty-six hours the whole body, including the 
palms and soles, is involved. While spreading thus, the papules on the 
face are enlarging peripherically until they become confluent and large 
areas are covered, with only here and there small areas of intervening 
normal skin. This process takes place also on the rest of the body in the 
order in which the eruption originally appeared. The whole face is swollen 
and has a characteristic mottled appearance when the eruption is at its 
height. The lids are red and edematous, and the conjunctiva inflamed, 
tending to keep the eyes half-closed. Photophobia is pronounced. This 
condition is usually reached within thirty-six hours after the first appear- 
ance of the eruption, and continues together with the maximum tempera- 
ture, coryza and cough, for one or two days. During the next two days the 
eruption fades and the temperature falls, so that within seven or eight days 
from the onset of the first symptoms the temperature is normal and desqua- 
mation is taking place. 

Desquamation begins in the order in which the eruption appeared, 
often beginning on the face as the exanthem has reached its height on the 
limbs. It consists of fine flakes unlike the large lamellae of scarlet fever. 
It is completed in one or two weeks. 

Variations, Complications and Sequellae. — The incubation may 
last as long as twenty-one days. There may be no symptoms of rhinitis 
or bronchitis whatever, throughout its course. Belapses, i.e., recurrences 
of temperature and eruption, are very rare, but may occur a few days after 
the temperature has become normal. 

Fever. — There are afebrile cases and cases with hyperpyrexia, but 
neither are common in uncomplicated measles. The remission of tempera- 
ture on the second day of the prodromal stage may not occur, but the 
majority of cases show it. A continued temperature after the eruption 
subsides, or a persistent rise of temperature during the first or second Aveek 
of convalescence always leads us to suspect complications, particularly bron- 
chopneumonia or middle-ear infection. 

Exanthem. — Occasionally the eruption itself is so atypical that a 
diagnosis can only be made by a general consideration of the other features 
of tbe case. Rarelv it mav be erythematous or even vesicular in character, 



THE EXANTHEMATA. 217 

or the papules may be very large or macular from the first. They may 
vary from the typical red color to purple or, on the other hand, they may 
be very faint pink. There may be minute hemorrhagic spots about the 
papules even in benign cases ; or in the severe toxic and often quickly fatal 
cases the hemorrhagic areas are extensive and simultaneous hematuria and 
epistaxis occur. In weakly children the eruption is often very limited even 
in severe cases. It may vary in the order of its appearance, coming simul- 
taneously upon the face and thorax, or even on the thorax or abdomen first. 
It may subside entirely in twenty-four hours. Entire absence of the erup- 
tion is very rare, if it occurs at all. 

Lungs. — Here we find the most common and the- most dreaded com- 
plications of measles. A mild bronchitis with coarse mucous rales through- 
out the chest is very common during the early stage, and may pass off with 
the eruption. But often this outcome is not so fortunate, for it may con- 
tinue into a chronic bronchitis; or while the disease is at its height the 
respirations may become more rapid, localized areas of fine crepitant rales 
appear, and bronchopneumonia may develop. Its course differs in no way 
from the ordinary bronchopneumonia, being the cause of death in the great 
majority of fatal cases. It may occur at any time between the beginning 
of the prodromal stage and the completion of desquamation. Lobar pneu- 
monia is seen less frequently. The above-mentioned conditions of the 
respiratory tract make good soil for the growth of the tubercle bacillus, so 
that measles is one of the most frequent sources of pulmonary tuberculosis 
in childhood. Continued involvement of pneumonic areas with persistent 
cough, temperature and bronchitis should receive prompt attention, and the 
physician should have this complication constantly in mind. 

Pertussis is a very serious complication. Pleurisy and empyema are 
less common complications. 

Xose, Pharynx, and Larynx. — The inflammatory conditions here 
may cause enough obstruction to lead to much difficulty in feeding or in 
breathing. 

Spasmodic croup, a pseudomembrane of streptococcic origin or a double 
infection with the diphtheria bacillus may complicate the case. Diphtheritic 
croup complicating measles is very fatal, owing to the rapid descent of the 
pseudomembrane into the bronchial tubes. Ulceration of the larynx may 
cause great edema with extreme dyspnea or subsequently the scar may cause 
a serious stenosis of the larynx. 

Ear. — The external auditory canal may be painfully swollen through 
extension from the skin. Otitis media is often of a mild grade when due 
to infection through the blood, but severe cases are due to extension through 



218 DISEASES OF CHILDREN. 

the Eustachian tube. Mastoid disease has its usual relation to the otitis 
media, and is a fairly common complication in the purulent otitis cases. 

Eye. — Conjunctivitis is of the usual type in a more or less severe form. 
Keratitis and iritis may result and do permanent damage to the eye. Any 
previous condition may be rendered more active. 

Other Organs. — The intestines are occasionally involved, and the 
resulting diarrhea is often severe. Stomatitis may occur from the same 
source. Cerebrospinal meningitis is occasionally seen, particularly in the 
pneumonic cases. The heart and kidneys are rarely affected in uncompli- 
cated measles, although the kidneys may show transient abnormalities 
through the urine. Osteomyelitis and suppuration of the joints have been 
seen, but are rare. 

Prognosis. — The mortality from measles itself is not high, but the 
pulmonary complications render it one of the most serious of children's 
diseases. Fatal cases almost invariably show bronchopneumonia or less 
frequently lobar pneumonia. The mortality averages 8 to 10 per cent., 
and is greatest during the first year. Epidemics in institutions often give 
a high mortality. 

Prophylaxis. — ■ Measles is by no means a mild disease. Through its 
complications it is productive of many deaths. All possible precautions 
should be taken against exposure, especially of those under three years of 
age. Isolation should be carried out just as soon as the disease is suspected 
and should last at least three weeks. Children who have been exposed 
should be kept segregated from other children for that period. 

Treatment. — Hygienic and hydrotherapeutic measures are of greater 
importance than the medicinal treatment. Select a well-ventilated room 
that is as far as possible from direct communication with the rest of the 
house. The light should be thoroughly subdued with dark shades or eye 
screens until all photophobia is past. If the fever is high and causing 
ill effects, such as delirium, it can be controlled by sponging with luke 
warm water and by frequent drinks of cool water. If a sedative seems 
necessary, small doses of phenacetin will have the desired effect (one grain 
for a two-year-old child every two hours for four doses). The cough in the 
early days of the eruption is often troublesome and prevents sleep. Small 
doses of the bromid of sodium with chloral or codein may be given for its 
control. (Four grs. bromid with one gr, chloral every four hours for a 
child of five years or codein phosphate 1/24 of a grain for one or two doses.) 
Ammonium chlorid and sweetened cough mixtures only tend to produce an 
irritable stomach and consequent anorexia. The eyes should be bathed with 
4 per cent, boric acid solution. In some cases there is considerable itching 



PLATE VII. 




Rubella (German measles). 



THE EXANTHEMATA. 219 

of the skin, and this may be relieved by inunctions of 5 per cent, ichthyol 
and lanolin, or 2 per cent, carbolic ointment. The bowels are kept open, 
preferably with small doses of calomel or enemata. The ears should receive 
careful daily inspection for any redness or bulging, and if present incision 
and drainage of the ear drum may be indicated. By careful attention to the 
eyes, ears, and nasopharyngeal toilet, many of the disastrous complications 
of measles may be avoided. Bronchopneumonia, as a rule, supervenes more 
often in those cases that have been treated by sweating and administration 
of hot drinks, thus further lowering the resistance of the child. The diet 
should be light until the temperature has been normal for several days. 

German Measles. 

(Rdthehh, Rubeola.) 

Definition. — German measles is a mild acute contagious disease, hav- 
ing a period of incubation, a prodromal stage followed by a red macular 
eruption and desquamation. It is attended by little if any systemic dis- 
turbance. 

Etiology. — There is no known specific microorganism. The disease 
spreads with great rapidity, the contagium taking place on slight contact. 
It is conveyed by direct contact, and is probably not carried by a third 
person. One attack usually protects, but it has occurred in the same indi- 
vidual a number of times. Neither scarlet fever nor measles render im- 
munity, as it seems to bear no relation to these diseases. 

Pathology. — There is no specific pathology. 

Symptomatology. — After an incubation of between two and three 
weeks, during which there are no symptoms, a slight coryza or sore throat 
develops with a temperature rarely over 101° F. In a great many cases 
these prodromal symptoms are wholly lacking, and in about 50 per cent, 
there is no temperature at any time. There is rarely more than a slight 
indisposition and loss of appetite. On the first or second day the eruption 
appears. Often a premonitory general blushing of the skin, fading in a few 
hours, with small discrete macules, deep pink in color, are seen on the face. 

These rapidly spread to the thorax, and thence within twenty-four 
hours to the rest of the body, but they are much more numerous on the face 
than elsewhere. The eruption never reaches its height in all parts of the 
body at the same time, as it begins to fade on the face before the extremities 
are reached. The throat is reddened. If there has been any fever it dis- 
appears soon after the eruption comes out. Tn two to four days the eruption 
has faded, and a slight brownish staining of the skin, with slight desquama- 
tion, is at times seen. The posterior and occipital lymph nodes are very 



220 DISEASES OF CHILDREN. 

constantly enlarged, even before the appearance of the eruption, and confirm 
the diagnosis. Hess showed that in almost all cases of German measles 
there was a definite increase in the lymphocytes, even preceding the appear- 
ance of the exanthem. This fact should be utilized in institutions where 
an epidemic is in progress to separate the infected from the non-infected 
children. 

Prognosis. — Recovery after a short mild course is to be expected. 

Treatment. — This is, as a rule, mainly symptomatic. Beyond a liquid 
diet and sponging with alcohol very little is required. In severer cases the 
treatment given under Measles may be appropriately followed. The chil- 
dren are isolated for a period of two or three weeks, and their surroundings 
should be such as described under Measles. 

Scarlet Fever. 

(Scarlatina.) 

Definition. — « Scarlet fever is an acute infectious, and contagious dis- 
ease, characterized by a sudden onset, vomiting, and a generalized scarlet 
rash, accompanied by high fever. 

Incubation. — Varying periods of incubation are recorded. In our 
experience two to seven days after exposure the symptoms appear. The 
German authors give an incubation period from eight to eleven days. 

Etiology. — The specific causative factor is still unknown. It occurs 
more often between the ages of one to five. The incubation period is the 
least contagious, while the eruptive stage is the most contagious. The stage 
of desquamation was formerly considered the period of greatest danger. 
One attack, as a rule, protects the individual from subsequent attacks. The 
immediate neighborhood of the patient is probably a contagious zone. The 
secretions, particularly of the nose and throat, are active in carrying the 
infection. It is not now believed that the desquamated epithelium is the 
principal agent in the spread of the disease, as was formerly taught. 

Pathology. — The lesions found vary greatly with the intensity of the 
infection, and are due to the action of the scarlatinal toxin (streptococcic) 
or to a mixed infection. The heart muscle and the kidneys show degenera- 
tive changes in complicated cases. The cervical glands are found hyper- 
trophied. . 

Symptomatology (Simple Form). — Vomiting is usually the first 
symptom. Convulsions may usher in the disease in younger children. The 
child has fever and within twenty-four hours the rash appears, first upon 
the neck and chest. It is bright in color, diffuse, pin-point, with no areas 
of healthy skin in between : it rapidly spreads downward to the arms. 



THE EXANTHEMATA. 221 

trunk, and legs. The face is not as much affected as the rest of the body. 
Sometimes hardly any rash appears there. The rash is accompanied by a 
variable amount of pruritus. The tongue is coated quite heavily and often 
has the so-called raspberry appearance, due to the injection of the papillae. 
Later the tongue takes on a red beefy appearance, when the coating disap- 
pears. The fauces and tonsils are congested. The fever ranges from 102° 
to 104° F., with a rapid pulse. The glands in the cervical region are tender 
and often become swollen, especially in the later stages of the disease. The 
urine will show traces of albumin, which is often only temporary. It is apt 
to be scanty and high colored. 

The blood shows a leukocytosis, while a differential count may assist 
in the diagnosis by showing an increase in .eosinophils quite early in the 
disease. 

Desquamation. — This begins with the fading of the rash about the 
second or third day. The skin appears in fine scales, usually seen first on 
the face and about the joints, then over the body. On the hands often large 
sections of skin are shed. The process lasts many days, sometimes weeks, 
but can generally be assisted by the treatment given below. 

Anginal Form. — The tonsils and retropharynx are congested. The 
tonsils may show exudation in their lacunar spaces, and the cervical lymph- 
glands are much enlarged. In another form, a membrane may be present 
on both tonsils, spreading to the adjacent fauces, and gave rise to the false 
term of diphtheritic scarlet fever. It is due to a streptococcic infection, 
and should be regarded as the septic form of this disease, as in these cases 
there is always more or less general systemic infection. 

The fever in this form is usually of a remittent character and will be 
influenced by any complications that may arise. The severe forms cause 
prostration, stupor, or profound coma. The temperature remaining about 
105° F. with rapid pulse. The urine is scanty and high colored. Deglu- 
tition is extremely difficult. There is marked restlessness. The membrane 
may invade the nose or larynx, the lips are fissured and excoriated, while 
the breath is extremely fetid. 

Eoutine examination of the ears will show some degree of involvement 
in more than a fifth of the cases; if the patient goes on to recovery the 
lymph-glands are apt to degenerate with the formation of abscesses. Men- 
ingeal symptoms may precede a fatal issue. 

The mastoid cells may become diseased after convalescence has set in. 
Septic thrombosis and cerebral abscess are fortunately rarer complications. 
The otitis media of scarlet fever may persist, and become the cause of 
partial or absolute deafness. 



222 DISEASES OF CHILDREN. 

Kidneys. — Modern methods of urine examination will show traces 
of albumin and a few hyalin easts even in mild attacks. This should not 
be regarded as a true nephritis. The septic form of the disease through the 
agency of its toxins is more likely to be complicated by a true nephritis. 

Pumness of the eyelids and face, edema about the ankles spreading to 
the rest of the body will be the first objective signs. The urine then per- 
sistently contains albumin and mixed casts, with a high specific gravity. 
The nephritis usually lasts through a protracted convalescence or may 
become chronic. Uremic symptoms begin with vomiting or convulsions, 
sometimes only convulsive movements are observed. Coma with feeble 
heart action are symptoms of grave peril. 

The Eash. — The development of the rash, usually after twenty-four 
to forty-eight hours, offers considerable information of value in differen- 
tiating scarlet fever from the confusing erythematous eruptions. The ex- 
aminer should place his patient in a good white light. A magnifying glass 
and a glass slide, such as is used for blood and sputum, will be found to be 
exceedingly helpful in studying the exanthem. The rash first makes its 
appearance on the sides of the neck, upper part of the chest and face ; 
thence spreads to the arms, upper part of the back, and finally involves the 
trunk and lower extremities. Its color is not scarlet, but a dull red, almost 
a brownish-red (Fig. 3, Plate IX). This color varies proportionately to 
the fever, being more marked usually in the evening. The general char- 
acteristics of this rash about to be described will always be found present 
in a true case of scarlet fever, even though certain modifications or variations 
are observed. Close inspection of the rash resolves it into two factors, which 
are constantly present: 1. An erythematous background; 2. small, deep 
red, injected puncta (Fig. 5, Plate IX). Sometimes variations in the rash 
just described are present which give a diffuse, a mottled, or a speckled 
appearance. These changes are caused either by the closer merging or by 
the non-extension of these puncta with their erythematous areola. A normal 
or pale flesh tint is seen on pressure with a glass slide early in the disease, 
while later there is a dirty, yellowish-red pigmentation. Itching is quite a 
constant symptom, but is more marked when many groups of miliary vesi- 
cles are present. At the height of the eruption it is often possible to find 
small pin-point, conical, whitish vesicles, with a serous content, over the 
chest and lower abdomen (Fig. 1, Plate IX). When they occur in groups 
about the axillae or in the groins, they are quite confirmatory from a diag- 
nostic standpoint. The harsh, uneven feel which the rash occasionally gives 
to the hand passed over the skin is due to papular or even vesicular eleva- 
tions occurring at the sites of the hair follicles. This papulation affords 



PLATE VIM. 




Rash of scarlet fever. 



THE EXANTHEMATA. 223 

another valuable aid, as it does not disappear with the erythematous rash, 
but the roughness of the skin persists after it has faded. 

Certain regional characteristics are present in this exanthem, which, 
if appreciated, tend to help the puzzled physician. The face, for example, 
shows the true rash only on the temples ; the cheeks are profusely red, but 
the nose. chin, and upper lip appear unduly pale, causing a circum-oral 
pallid ring which should be sought for in suspected cases, as it is not present 
in the counterfeiting rashes. 

The flexor surfaces of the joints deserve careful scrutiny and special 
mention. These regions rarely exhibit the characteristic rash ; they are 
apt to be the site of petechial hemorrhages or else they have a blotchy 
appearance. 

If the palms and soles are examined with the magnifying glass, no 
puncta are seen, only a simple erythematous blush. 

Desquamation. — In the exfoliation of scarlet fever we expect to find 
it occurring in the order of the appearance of the exanthem. At first there 
are observed fine discrete scales in the infraclavicular and episternal regions 
(Fig. 6, Plate IX). These scales are made up of the epidermal covering 
of the above-described puncta and vesicles. When desquamation first occurs 
flakes having a perforated center are cast off. This is known as " pin- 
holing." Later, and continuing for five to seven weeks, the skin becomes 
rougher, throwing off irregular rings of desquamation of varying extent. 
The large strips of epithelium and casts of the hands and feet, which are 
sometimes shed or torn away, are more often seen in those subjects who 
have a skin of coarse texture. 

Another diagnostic feature of this stage of desquamation is seen in the 
finger-nails. If the pulp is pushed back from the nail, there will be seen 
just beneath its free border a scaling or cracking line which extends up to 
the fingers. Four to five weeks after the beginning of the disease we may 
find a transverse linear groove, sometimes with a corresponding ridge, which 
shows itself on the roof of the nail. The thumb-nail exhibits this condition 
better than the fingers. These nail changes serve as corroborative evidence 
in the subsequent diagnosis, and this desquamation may be seen on the 
nails when other evidences are not found elsewhere. On the other hand, 
it must not be forgotten that the desquamation may be so slight as almost 
to escape notice. Unfortunately, desquamation alone is often regarded as 
sufficient evidence of the disease, and a diagnosis is based thereon. In view 
of the fact that so many of the erythematous eruptions produce skin exfoli- 
ation, we are not justified in this conclusion, unless we have (1) the 



224 DISEASES OE CHILDREN. 

regional involvement, (2) the pin-holing, and (3) the nail changes, plus 
other pertaining clinical symptoms. 

The Tongue. — The tongue in the first days is usually thickly coated, 
and the papillae are obscured, but as the tongue clears up at the edges and 
tip, we can observe the enlarged papillae (Fig. 4, Plate IX), which become 
more and more prominent, and show at their best about the fourth day. 
The lingual mucous membrane now begins to exfoliate ; the tongue becomes 
red, dry, and glistening. It is in the posteruptive stage that this feature is 
particularly of diagnostic importance. 

The Blood. — The blood in" scarlet fever has been carefully studied, 
and may be of service in obscure cases, as an additional confirmatory link. 
The red blood-cells are gradually diminished throughout the course. A 
leukocytosis is present a day or two before the appearance of the rash, and 
the normal is regained only in convalescence. We have found this leukocy- 
tosis to be proportionate to the severity of the angina. The polynuclears are 
increased and the mononuclears decreased, both relatively and absolutely. 
To the eosinophiles we may look for some rather characteristic variations. 
In the initial stages they may disappear almost entirely, while in deferves- 
cence, and later to the sixth or seventh week, 8 to 12 per cent, may be 
counted. 

Differential Diagnosis. — >The Eryihemata. — Erythematous eruptions 
which may simulate the rash of scarlet fever are quite common ; and if a 
careful examination and study of the rash is not made, weighing with it all 
the clinical evidence, mistakes are easily made. The simple form of ery- 
thema results from external irritants, while the exanthem of angioneurotic 
origin results either from systemic disturbance, ingestion of certain drugs, 
or from specific poisons. These fortunately have certain characteristics 
which should be borne in mind, for while we are not always able to distin- 
guish them one from the other, the differentiation from scarlet may be thus 
made possible. 

One of the striking features is the tendency to recurrence, and undoubt- 
edly many of the so-called second and third attacks of scarlatina have been 
in this class. In a general way these dermatoses are distinguished by the 
following peculiarities : They may appear in any region of the body — at 
one time there may be present in the erythema elements of the various exan- 
themata. Their type may rapidly change so that they may be scarlatini- 
form one day and morbilliform the next. The puncta seen in the scarlet 
fever exanthem are absent. Desquamation is coarse and flaky, and recur- 
rences are frequent. 



THE EXANTHEMATA. 225 

Erythema Scarlatiniforme. — This is a non-contagious dermatitis, 
simulating scarlet fever in its cutaneous manifestations. It is liable to 
occur secondarily to other infectious diseases and to medicinal and food 
intoxication. As it is important to differentiate the disease from scarlatina, 
its distinguishing features will therefore be given. 

This erythema spreads very rapidly, sometimes reaching its height in 
a few hours. Patches of erythema may alone be present. Under the glass 
there is no uniform redness. The face is rarely involved and the tongue 
shows no " raspberry " appearance. The fauces may be red, but are not 
swollen. Desquamation takes place at an early date after the erythema, 
sometimes on the second day; it is a quick process and. the scales are large, 
abundant, and furfuraceous. The course is brief, and there are no compli- 
cations or sequela?. Such a clinical picture, especially in a child who has 
given a history of previous similar attacks, should exclude scarlatina. A 
scarlatinoid erythema may follow the use of such drugs as belladonna, 
quinin, chloral, chloreton, salicylic acid, antipyrin, digitalis, opium or 
veronal, especially in those patients having a drug idiosyncrasy. These 
eruptions almost invariably follow very quickly after the ingestion of the 
drug. We have seen it occur within an hour after a dose of antipyrin. 
The close relationship to the drug taking is a diagnostic feature of consider- 
able value. Belladonna rashes are perhaps most often seen. This eruption 
is usually confined to the face, neck, and chest, and is only rarely general- 
ized. It fades quickly and is rarely followed by any desquamation. The 
absence of fever, the dilated pupils, the evanescent rash and the history 
should cause no confusion. 

It is well to recollect that drug rashes in general, and in contrast to 
scarlet fever, appear for the most part on the extensor surfaces of the 
extremities, and if they be present on the face, then the circumoral ring is 
not observed. Moreover, they are not associated with fever, angina, or 
adenitis. If any doubt still exists, the repetition of the dose of medication 
under suspicion should be given to reproduce the erythema. 

Acute Exfoliative Dermatitis. — Another disease which may raise 
a veritable doubt in the stage of efflorescence or in the desquamative period 
is acute exfoliative dermatitis. It differs in that the constitutional symp- 
toms are more pronounced than in scarlatinoid erythema, while the eruption 
appears as a general hyperemia very soon covering the entire body. The 
exfoliation follows in a day or two. and is general in character and intensely 
profuse: large papery strips being cast off (Eig. 8, Plate IX). The nails 
and hair may drop out before the process is complete. 
15 



226 DISEASES OE CHILDREN. 

Another disease which necessitates correct interpretation is the scar- 
latiniform variety of rubella; fortunately, this is not a common type (Fig. 
7, Plate IX). Close inspection of the rash will disclose morbilliform char- 
acteristics. The mild constitutional symptoms and the enlarged postcervical 
glands of rubella will define it. 

Serum Rashes. — The use of antitoxic serum may be productive of a 
scarlatinoid rash that is very puzzling. This is especially true when anti- 
diphtheritic serum has been injected. The angina of the diphtheria is 
already present and cannot assist us, while fever and malaise supervene. 
We must then depend upon the following facts : That the rash frequently 
spreads from the site of the injection; that these rashes are often polymor- 
phous in character and fleeting in duration. They appear on the third or 
fourth day, the eruption occurs usually in patches and only rarely appears 
on the face. A well-marked enlargement of the superficial lymph-glands 
in the inguinal, axillary, and epitrochlear regions will also help to distin- 
guish this rash from scarlatina. 

Open wounds and especially burns are liable to direct inoculation. 
Many of the so-called cases of " surgical scarlet " of the older writers were 
probably scarlatinoid erythemas or what we now recognize as septic rashes. 
For our guidance in differentiation the wound is of considerable help; an 
erstwhile healthy wound may begin to look unhealthy, and an exudate may 
form upon it. The rash is very likely to first appear at or near the wound. 
The nearest lymphatic nodes will be found tender and enlarged. Vomiting 
may occur, but sore throat is rarely complained of. There are no charac- 
teristic changes in the desquamation. 

The septic rashes which were referred to above occur more often in 
early life, and either precede or accompany a definite septicopyemia. Occa- 
sionally they may indeed be the first to call attention to the true condition 
of the patient. When the rash is small and macular, it may resemble scarlet 
fever. Its spotted character and the large macules which are seen on the 
extensor surfaces of the extremities with absence of puncta fix the diagnosis 
(Fig. 9, Plate IX). A high leukocytosis would be confirmatory. From 
erysipelas, scarlatina can be distinguished by the shining, glazed appearance 
and characteristic spreading. 

The Fourth or Duke's disease is of interest in this connection because 
of its confusion with scarlet fever, provided we accept the dictum that 
attacks of the Fourth disease do not protect the individual against scarlet 
fever and measles. The disease is described as differing from scarlet fever 
in its longer incubation period, absence of prodromal symptoms, such as 
vomiting, high pulse rate, and severe angina. The rash itself shows but 



PLATE IX. 




The differential diagnosis of scarlet fever and the Scarlatiniform eruptions. 
1. Scarlet fever rash showing sudaminal vesicles. 2. The fading scarlatina erup- 
tion. 3. Scarlatina eruption, early stage. 4. Typical scarlet fever tongue. 
5. The scarlet fever rash, magnified. 6. Scarlet fever desquamation. 7. The 
scarlatinal form of rubella. 8. Acute exfoliative dermatitis. 9. Erythema in- 
fectiosa. (Pisek's original plate; courtesy Archives of Diagnosis.) 



THE EXANTHEMATA. 227 

little difference except that it usually begins on the face and is not exten- 
sive. The desquamation, however, is profuse and out of all proportion ta 
the exanthem. Penal complications do not occur. 

As the practitioner is often called upon to offer a diagnosis at different 
stages of the disease, the distinctly helpful phenomena to be observed at 
various stages in scarlatina will be given. 

Preeruptive Stage. — Here the diagnosis is only rarely possible and 
then it can be made only in the presence of an epidemic and a history of 
contagion. The sudden invasion with an angina, bright red puncta seen in 
the roof of the mouth, and initial vomiting without satisfactory cause, may 
be symptoms anteceding the eruption. The polymiclear cells are increased, 
while in rubella the lymphocytes appear in greater numbers. 

Eruptive Stage. — The diagnosis is at this period rarely obscure. 
The vomiting, high pulse rate, characteristic punctate rash, congested fauces 
and evidences of the " raspberry " tongue are usually conclusive. 

Predesquamative Stage. — The rash has faded or disappeared, and 
desquamation has not yet begun. Here the distinctively glazed, papillated 
tongue and the injected fauces are seen. The enlarged lymph nodes be- 
neath the maxilla are tender to the touch. The skin looks dirty yellow 
under a glass slide, and has a distinctly dry and uneven feel. Sudamina or 
miliary vesicles may be present in groups. 

Desquamative Stage. — When the disease is seen late, exfoliation 
beginning on the face may be found on the fourth to the sixth day of the 
disease, and on the neck and chest about the twelfth to the fourteenth day. 
On the palms of the hands and soles of the feet it persists sometimes for 
weeks; this possibly serving to differentiate it from the scarlatiniform 
erythemas. " Pin-hole " scaling on the body and the lines on and beneath 
the finger-nails strengthen the diagnosis. It is not uncommon to find still 
further corroborative evidence at this stage in complications of the kidneys, 
joints, in the ear or in suppurating cervical glands. 

Prognosis. — In the mild cases this is extremely good. The septic 
cases in the epidemics raise the mortality. In this country the mortality 
in several epidemics averaged 3 per cent. Xephritis is the most common 
complication and often a fatal one through uremia; the chronic form react- 
ing badly to treatment and often ending in death. Otitis and its compli- 
cations may result in deaf-mutism or have a fatal issue through the involve- 
ment of the brain or sinuses. The involvement of the serous membranes of 
the heart or joints tends to a grave prognosis. The older the patient the 
better the prognosis. 



228 DISEASES OF CHILDREN. 

Treatment. Prophylactic— The routine examination of school chil- 
dren which is now practised in a number of the largest cities will notably 
tend to diminish the number of scarlet fever cases and prevent epidemics. 
Isolation should be insisted upon, and be carefully carried out even in mild 
or suspected cases. Children or even adults who have been subject to 
pharyngitis or tonsillitis are more likely to take or spread the infection. 
Air and sunlight should be regarded as the best disinfectants. 

Children from whom enlarged tonsils and adenoids have been previ- 
ously removed are less liable to such complications as otitis and sinusitis. 

Sick-room and Quarantine. — A quiet sunny room that can best be 
used for purposes of isolation should be selected. An open fire-place is 
preferable to any other form of heating. 

All unnecessary furniture should be removed, a gown or sheet and a 
bowl of bichlorid of mercury (1/1000) should be placed in readiness in an 
empty closet outside of the room for the use of the doctor. 

During convalescence toys of little value, that can be burned, should 
be provided so that the period of quarantine, which is usually six weeks, may 
not be too irksome for the child. 

Disinfection can be carried out as described on page 300, when the 
patient is ready to be discharged. 

Routine Measures. — All cases of scarlet fever, whether mild or severe, 
should be regarded as dangerous, as the complications and sequelae may 
permanently injure the patient. Skilled nursing will do more to promote 
the comfort, progress, and the prevention of complications than remedial 
measures. If circumstances will not permit of a trained nurse, some one 
member of the household should be put in charge and given careful instruc- 
tions as to the quarantine regulations and written orders for the patient. 

The diet should consist wholly of milk in the first few days of the ill- 
ness, later, for the sake of variety, fruit juices, whey, buttermilk, or matzoon 
may be added or substituted. 

When convalescence is established, gruels, crackers, well-toasted bread, 
and apple sauce may be added to the dietary. Vegetables and eggs are 
allowed in the fourth or fifth week if there is no fever or other contra- 
indication. Water should be offered often and freely throughout the illness. 

The skin should be anointed with a 5 per cent, boric acid ointment or 
with liquid albolin daily as soon as desquamation is established. If the 
pruritis is troublesome a 1 or 2 per cent, carbolic acid ointment will be 
effective in its control. 

The nasopharyngeal toilet should be made daily with a mild alkaline 
antiseptic or a normal saline solution. The method employed will depend 



THE EXANTHEMATA. 229 

upon the age of the child. Those who are old enough and willing may gargle. 
A spray or irrigation is necessary for the obstreperous or septic cases. The 
solution may be instilled with a medicine dropper into the nares of infants. 

The Urine. — A specimen should be obtained for examination (see 
Methods, page 425) three times a week. If this is done the complicating 
nephritis will be detected early and proper measures can be taken at once. 

Symptomatic Treatment. — The fever, if high, above 104° F., can be 
controlled by sponging with water 85° to 90° F. every two or three hours. 
Cool packs are rarely necessary except in those cases in which there is con- 
siderable restlessness and delirium. The child may then be wrapped in a 
sheet as described on page 70 and left in this for a few hours if sleep is 
produced. 

Heart. — Persistent high fever, especially in the septic cases, may 
weaken the action of the heart so that the pulse becomes soft and somewhat 
irregular. The first sound is not distinct and the pulse rate becomes high. 
Stimulation with strychnia alternating with the tincture of strophanthus is 
now indicated. Alcohol in the form of sherry wine (vini xerici) may be 
substituted profitably in the septic cases. One to two ounces may be given 
freely diluted in water during the twenty-four hours to a five-year-old child. 
Xormal salt solution, two to three ounces, given by hypodermoclysis may 
tide over a critical period. 

The bowels are kept open preferably with the effervescent citrate of 
magnesia. Constipation, which is so often present on a strictly milk diet, 
will not be so troublesome if the dietary is varied as outlined above. The 
milk of magnesia may be added to the bottle in infants. 

Complications and Sequelae. — The cervical adenitis which so often 
occurs requires the use of ice-bags or compresses of a saturated solution of 
magnesium sulphate in the early stages. Ichthyol ointment 20 to 30 per 
cent, in lanolin is applied daily when the acute symptoms have subsided. 
The abscess must be incised and drained if fluctuation denoting suppuration 
is detected. 

Nephritis will necessitate the continuance of a liquid diet, alkaline 
diuretics, or such drugs as diuretin or agurin, and in the graver cases high 
colonic irrigations of saline solution twice a day until the normal amount 
of urine in secreted. 

Otitis. — The ear drums should be examined every other day as a 
routine measure, and any redness and bulging should receive prompt treat- 
ment by incision and drainage as outlined on page 532. If this is done, 
chronic otitis and mastoid infections with their sequela? may be avoided. 



230 DISEASES OF CHILDREN. 

Arthritis occasionally occurs as a complication which prolongs the 
convalescence, and if neglected may cause joint deformities. Arthritis at 
times occurs as a complication, usually in the third week. A normal con- 
valescence may be disturbed by a rise of temperature which cannot be 
accounted for. In about 24 hours the patient may complain of pain in the 
joints, principally the knee, the wrist, or the joints of the fingers being 
affected. The pain is best elicited by transverse pressure across the joint. 
We have occasionally observed a fine erythematous rash preceding the 
arthritis. Prolonged hot baths and the application of a saturated solution 
of magnesium sulphate give most relief. Small doses of aspirin are 
sometimes needed. 

The Serum Treatment. — Except in those cases which by culture give 
evidences of an added Klebs-Loeffler infection, serum therapy as thus far 
elaborated is without value. Diphtheria antitoxin should be administered 
in those cases in which a true diphtheria is present, clinically or by culture. 

Small-pox. 

(Variola.) 

Definition. — Small-pox is an acute contagious disease characterized 
by a period of incubation, a prodromal stage with intense constitutional 
symptoms, followed by a progressive eruption of macules, papules, vesicles, 
pustules, and cicatrices. 

Etiology. — Specific. — Councilman in 1903 discovered a protozoan 
in the skin of small-pox patients. The relation of these parasites to the 
skin lesions is of such a definite and intimate character as to lead to the 
conclusion that they are the cause of the disease. They have a double life 
cycle, intracellular and intranuclear, which they undergo in the epithelial 
cells. In the first cycle they are small homogeneous bodies found in vacuoles 
in the cells of the lower layer of epithelium, and develop there into large 
ameboid multi-chambered organisms, destroying the epithelial cell and by 
segmentation breaking up to form the protozoa of the second cycle. These 
invade the nuclei of other epithelial cells and continue their growth until 
the cell is destroyed. The parasite has not been found free in the vesicle 
contents, nor anywhere, as yet, except in prepared sections of the skin. 

Non-specific. — The contagium exists in the secretions and excretions, 
in the skin lesions, and in the dried scales and crusts that come from them. 
It clings to everything with which it comes in contact, and may therefore be 
transmitted by a third person ; all public places are thus dangerous for an 
unvaccinated individual during an epidemic. It is probably contagious 
during the prodromal stage as well as throughout the course of the eruption 



PLATE X. 




Differential diagnosis of variola and varicella, (a) variola; (6) varicella. 



THE EXANTHEMATA. 231 

and desiccation. A very virulent case of variola may be contracted from the 
mildest varioloid. Vaccination protects for a variable time (six years to a 
lifetime) in different individuals, and always lessens the danger and sever- 
ity of an attack. One attack protects for life. 

Pathology. — The papule is seen to be a focus of coagulation necrosis 
in the rete mucosa, surrounded by an area of active inflammation. The 
vesicle is made up of numerous recticulas and spaces which contain serum, 
leukocytes, and fibrin. When the pustule involves the true skin a per- 
manent scar results. 

Incubation. — Twelve to fifteen days. 

Prodromal Stage. — Three or four days. 

Symptomatology. Description of Prodromal Stage. — This is 
ushered in with convulsions, vomiting or a chill, and in older children 
severe frontal headache and backache are complained of. The temperature 
quickly rises from 103° F. often to 106° F. The pulse becomes rapid and 
full, and within twenty-four hours there may be delirium and marked rest- 
lessness. This condition continues with no diagnostic signs on the skin 
usually for four days, when the eruption appears. Simultaneously there is 
a fall of temperature even to normal in the less severe cases, and marked 
improvement in the general symptoms. 

The Exanthem. — At first the exanthem is in the form of small raised 
red papules, most commonly developing on the forehead, particularly at the 
junction with the hair, and on the wrists. They rapidly extend to the rest 
of the face and to the extremities, including the palms and soles, and in 
less numbers to the trunk. They all come out in one crop within twenty- 
four hours. They feel hard and have the so-called " shotty " touch, be- 
cause they extend deeper into the skin than other papules, as, for instance, 
those of chicken-pox. These same red papules are to be seen on the hard 
and soft palate and pharynx, causing an accompanying sore throat. In 
two days, sometimes less, the papules on the skin become vesicular, with a 
slight depression in the center of each vesicle, and if pricked with a needle 
they do not collapse because they are divided into many parts by a reticular 
construction. They still have an indurated reddened base. On the eighth 
day of the disease, four days after their first appearance, the vesicles be- 
come full and rounded and the serum in them changes to pus. The skin 
becomes tense and swollen, and the individual lesions enlarge, so that in 
the severe cases (confluent form) they coalesce and the face appears much 
swollen and changed beyond recognition. This is accompanied by a second 
rise of temperature (secondary fever), and a return of the constitutional 
symptoms with redoubled vigor. The delirium returns, the pulse grows 



232 DISEASES OE CHILDREN. 

weaker, and the patient shows every sign of a severe intoxication. In the 
fatal cases this may go on for two or three days with increased severity nntil 
death results. But in the milder cases, within twenty-four to thirty-six 
hours after maturation takes place, the pustules break and the pus exudes, 
and on the tenth or eleventh day the temperature begins to fall by lysis. 
The pustules rapidly dry with the formation of crusts, and usually during 
the third week the temperature becomes normal and the desiccated pustules 
alone remain. These may adhere for a week or longer until at last they fall 
off and leave the scar or pit which may, especially in the confluent form, 
be carried throughout life. A leukocytosis occurs in the pustular stage, 
but at no other time unless there is some complication to cause it. 

Variations, Complications, and Sequelae. — There are really four 
forms of small-pox, differing chiefly as to their severity : varioloid, discrete, 
confluent, and hemorrhagic small-pox. Varioloid is a pox modified by a 
previous vaccination, and does not often occur in children, since a child 
that has been successfully vaccinated is generally immune until after 
puberty. The mild discrete form is also unusual, because in unvaccinated 
children small-pox is apt to run a very severe course. These two forms are 
mild and differ only in degree. The symptoms are all milder than in the 
other two forms, although the initial temperature may be high. The 
papules are fewer in number, particularly on the face, and do not coalesce. 
The disfiguration is less. There is less secondary fever from suppuration 
(in varioloid often more) and convalescence is therefore much more rapid. 
In the confluent form the eruption is apt to appear earlier, about the third 
day, with a lesser fall of temperature upon the advent of the eruption. 
There is more swelling and distortion of the features during the suppurating 
and coalescing stage and more pain. Delirium, ceaseless, restless move- 
ments, and other nervous manifestations are prominent in children. Diar- 
rhea is also peculiar in children. The larynx and pharynx may be greatly 
swollen. Edema at times being the cause of death through suffocation. 
The cervical glands are much swollen and may suppurate. Hemorrhagic 
small-pox may show itself either before the real eruption appears or at the 
time of suppuration and secondary fever; the earlier the hemorrhage, the 
greater the danger. At first there are small punctiform hemorrhages. 
They rapidly increase in size, and soon hemorrhages appear from the 
mucous membranes, hematemesis, hemoptysis, epistaxis, and hematuria 
develop. Large conjunctival hemorrhages with deeply sunken cornea com- 
plete the picture. The pulse is rapid and the respirations frequent. On 
the other hand, hemorrhage into the vesicles themselves, with abortion of 



THE EXANTHEMATA. 233 

the rash and speedy recover)* even in cases that were previously considered 
severe, have been noted. 

Other complications are edema or necrosis of the larynx, which may be 
fatal. Bronchopneumonia is common, while heart and kidney complica- 
tions are rare. Arthritis going on to suppuration, and acute necrosis of 
the bones have occurred. The eye may be permanently injured by inflam- 
matory changes. Otitis media may complicate. Boils, acne, and ecthyma 
are apt to be troublesome sequela?. 

Prognosis. — ■ The matter of previous successful vaccination is the most 
important item in the course and termination of small-pox. 

In one large epidemic the mortality of the unvaccinated was 54 per 
cent., while that of the vaccinated was J of 1 per cent. In children it is 
particularly fatal. Of 3,164 deaths in the great Montreal epidemic, 85 per 
cent, of these were in children under ten years. The younger the child the 
more serious the course, and the more fatal the outcome. The hemorrhagic 
form is almost invariably fatal. The more numerous the lesions on the 
face the more grave is the prognosis, as is seen in the high mortality of the 
confluent form. High fever, delirium, continued convulsions and other 
nervous symptoms are particularly dangerous. Laryngeal and pulmonary 
complications are very fatal in children. 

Prophylaxis. — Vaccination is the measure which, if thoroughly car- 
ried out, would eradicate this disease. 

The strictest quarantine regulations must be enforced even in suspected 
cases: all individuals exposed are to be immediately vaccinated. The de- 
mand of school boards that all children be frequently vaccinated has been 
followed by the most satisfactory results. 

Treatment. — If the patient has not been vaccinated, and is in the 
incubation stage, the ravages of the disease may be prevented and only a 
mild course observed, if he be immediately vaccinated. The high fever is 
controlled by cold sponging and the use of the ice-bag under skilled super- 
vision. The racking pains are best controlled in children by Dover's pow» 
ders. "Water is freely demanded and should be freely given. Convulsions 
and other nervous phenomena may be prevented and relieved by insisting 
upon a cool temperature in the room; preferably at 65° to 70° F. The 
diet should be liquid during the febrile period. A 4 per cent, solution of 
boracic acid should be used for the eyes, mouth, and nose. A 2 to 5 per 
cent, iehthvol ointment will very effectively control the itching in the erup- 
tive stage. A great deal may be done for the patient during the stage of 
suppuration. Welch, who has had a large experience, recommends the 
application of a mixture of olive oil and lime-water -J oz. each with carbolic 



234 DISEASES OF CHILDREN. 

acid ten to fifteen drops. Elbow sleeves will effectively prevent the child 
from scratching and thus causing pitting and disfigurement. Martin states 
that he can prevent pitting by treating each pustule by incision and drain- 
age. The patient's strength is to be carefully watched and strychnin pre- 
scribed at the first signs of a weakening heart. In the convalescent stage, 
forced feeding will serve as the best tonic treatment. 

Vaccination. 

Definition. — Vaccination is the innoculation of an individual with 
the virus taken from the vesicle of a cow that has vaccinia or cow-pox. 

Etiology. — It is now known that vaccinia is caused by a protozoan 
which resembles that of small-pox, but which differs from the latter in that 
it has only one life cycle, the intracellular form described under the etiology 
of Small-pox. 

Value of Vaccination. — In the immense majority of cases vaccination 
renders the individual immune from small-pox for many years. Before it 
was generally practised terribly fatal epidemics swept over different parts 
of the world, carrying away enormous numbers of victims. Eotch stated 
that in the last fifteen years no deaths from small-pox occurred in Boston 
in children who had been vaccinated under five years of age, and at the 
same time the mortality in the unvaccinated was 75 per cent. Where small- 
pox is acquired after successful vaccinaiton, even years after, it is the mild 
form, called varioloid. 

When to Vaccinate. — Every infant should be vaccinated preferably 
between the fourth and sixth months of life, before teething has begun and 
before the child can disturb the dressing. An acute or a severe chronic 
disease is a contraindication except in an emergency. Eevaccination is 
advisable at puberty, and at any. other time when the child has been exposed 
to small-pox or during a general epidemic. If an unprotected child is 
vaccinated within two days after exposure to small-pox, it will probably not 
contract that disease, and if vaccinated within five days thereafter the 
small-pox will be modified, and it will convert a possibly severe case into 
a mild one. 

Method of Vaccination. — Only sealed tubes or quills should be used. 
Boys are vaccinated on the left arm at the insertion of the deltoid, girls 
on the thigh or calf. The skin is carefully cleaned with soap and water and 
a piece of sterile gauze. It is then washed with alcohol and allowed to 
dry. A large sewing-needle is sterilized by heating over a lamp. The skin 
is pulled taut without touching the place to be vaccinated and lightly 
scarified criss-cross without producing any bleeding. The vaccine is then 



THE EXANTHEMATA. 235 

unsealed, applied and gently rubbed in. It is next allowed to dry for 
twenty minutes, care being taken that it is not contaminated at this time. 
When dry a piece of sterile gauze is laid over it and firmly fastened with 
strips of adhesive plaster. Vaccination shields should not be used, as much 
contaminating dust and dirt may collect under them. The dressing should 
not be disturbed except by the physician for the purpose of seeing if the 
vaccination is successful and uncomplicated at the end of the week. It 
should be very secure in children who are old enough to tear it off. Vac- 
cination should be attempted at least three times with a different lot of 
virus each time before one should say that the child cannot be successfully 
vaccinated. 

Description of Normal Course. — The scarified area appears to be 
healing with no general symptoms until the third to fifth day, when a small 
papule develops at the sight of inoculation. This increases in size, and 
after one or two days develops into a large vesicle with a raised margin and 
depressed center, the whole surrounded by a red areola. By the eighth day 
it has attained its maximum, and on the tenth day the contents are purulent. 
The surrounding areola is extensive, swollen, indurated, and painful. The 
axillary or inguinal glands, according to the site of vaccination, are large 
and tender. On the eleventh or twelfth day the hyperemia diminishes and 
the pustule begins to dry up, and by the end of the second week only a brown 
crust remains which comes off in another week, leaving a round, pitted scar. 
Usually on the fouth or fifth day some fever and more or less marked con- 
stitutional symptoms develop and last three or four days. The vaccination 
has not been successful unless, 1. some reddened areola surrounds a typical 
vesicle; 2. there is some swelling of the lymph-glands; 3. some, even slight, 
fever and constitutional symptoms; 4. there should be a permanent scar in 
which even years after, numerous small pin-point-size depressions are seen. 
This last charactemstic is very valuable in determining the success of a 
vaccination for a number of years after. 

Variations and Complications. — ■ The vesicle may abort and dry up 
in seven or eight days, in which case revaccination should be practised. 
Generalized vaccina at times shows itself at the end of the first week by a 
vesicular eruption in any part of the body. It may continue to make its 
appearance for five or six weeks. It is not serious, as a rule, but has been 
known to be fatal. Recurrences of the vesicle at the site of the original 
vaccination are rare. "Reinoculation occurs in children who have scratched 
the original vesicle and then vaccinated themselves in different parts of 
the body. 



236 DISEASES OE CHILDREN". 

Infection with other organisms results from, 1. contaminated virus; 
2. lack of asepsis in vaccination; 3. traumatism and contamination during 
the vesicular stage. If the vesicle is not ruptured it is not liable to be 
contaminated, but with a sterile dressing over it there is double protection. 
The results of contamination may be ulceration more or less severe, or 
even an extensive necrosis ; suppuration of the lymph nodes ; septicemia or 
suppuration in the joints. Tetanus, syphilis, and tuberculosis are almost 
never seen now that animal lymph is used. Other complications are eczema, 
general urticarial and scarlatinif orm erythematous eruptions. These may 
occur from the first to the fifth weeks. 

Varicella. 

(Chicken-pox.) 

Definition. — Varicella is a short, mild, contagious disease, with a long 
period of incubation, a short prodromal stage, followed by an eruption of 
superficial papules going on to vesiculation. (See PI. X.) 

Etiology. — ~No specific microorganism has yet been discovered. It 
is an independent disease not closely allied to small-pox. It does not pro- 
tect from small-pox, nor does small-pox protect from it. The disease is 
most common between the ages of two and six years, and is rare after 
puberty. It is communicable on slight, short, contact, the mode of entrance 
not being known. 

Pathology. — The papule and vesicle are near the surface, being 
formed by the upper layer of the epidermis. The vesicle is seldom multi- 
locular, and unless deeper ulceration takes place, which occasionally occurs, 
it does not leave a scar. 

Incubation. — Ten to eighteen days, usually fourteen days. 

The prodromal stage lasts about twenty-four hours. 

Description. — After a day of slight malaise, with perhaps a temper- 
ature of 101° F. to 102° F., a few red papules, varying from pin-head to 
pea-size, are seen anywhere on the body. Usually they are few in number 
and scattered over the face, trunk, and extremities. The temperature may 
be lowered a degree or more after the eruption comes out, but the patient 
still has some constitutional symptoms. A slight sore throat is the rule, 
as a few of the same isolated red papules appear on the fauces and pharynx. 
Within a few hours vesicles take the place of the papules which first make 
their appearance, and at the same time another crop of papules appears 
scattered here and there, between them. This process continues three or 
four days, so that at any one time the lesions in their various stages may 
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238 DISEASES OF CHILDREN. 

vesicles, and those that are drying up. They may be an inch or two apart, 
or they may be much closer together. They usually have no umbilication, 
feel soft to the touch, and collapse when pricked with a needle. As a rule, 
they do not go on to pus formation, but contain a clear, or at most, a 
slightly turbid fluid. After two or four days they dry up, the temperature 
is normal, and convalescence is established. 

Variations, Complications and Selquelae. — Many children show 
little or no constitutional symptoms. Earely there may be a high fever, 
even to 105° F., and corresponding symptoms, but this is the exception. In 
some cases the eruption is profuse on the vulva and nates, with consequent 
vesical and rectal tenesmus. Occasionally one or two of the vesicles become 
infected and more or less deep destruction of tissue results. Cases of high 
fever and pustulation of all the vesicles, lasting a week or longer, have been 
reported. A depression in the center of each vesicle, that is, umbilication,. 
is not typical, but it occurs often enough to be misleading in differentiating 
an atypical case from small-pox. 

Albumin in the urine is not uncommon, but true nephritis is rarely 
seen, except in an unusually severe case. Acute simple inflammatory in- 
volvement of the joints, lasting only a few days, has been noted. Otitis and 
pneumonia are rare complications. 

Prognosis. — Eecovery is to be expected after a short mild illness. 

Treatment. — To prevent the transmission of the disease, isolation 
from other children should be insisted upon, for although the disease is 
mild it occasionally produces some serious consequences. The child should 
be kept from scratching the vesicles to present infection by the finger-nails. 
An initial dose of 1 gr. of calomel, and a liquid diet, are the only 
measures, as a rule, required during the illness. 

Diphtheria. 

Diphtheria is an acute infectious disease due to the growth and action 
of the Klebs-Loeffler bacillus on a vulnerable surface producing a local mem- 
brane and general toxic symptoms. 

Etiology. — The disease is endemic in large cities. Local epidemics 
frequently occur in small towns and villages. Statistics show the disease 
to be more prevalent in the winter and fall than in the summer months. 
In fact, vacation periods show a falling off in all infectious and contagious 
diseases. The disease is contracted directly or indirectly from another case 
of diphtheria or from diphtheria carriers. The indirect means are usually 
the handling of infected objects and attendants who do not take proper 
precautions. Even contaminated food, such as berries and milk, have been 



PLATE XI. 







Differential diagnosis of (a) follicular tonsillitis; (6) scarlatinal angina 
(c) diphtheria; (d) lacunar tonsillitis. 



THE INFECTIOUS DISEASES. 239 

known to infect the consumer. There is no discrimination as to sex; age, 
however, plays an important part. Xurslings possess considerable immu- 
nity. The third to fifth year is the period of greatest liability. From the 
tenth year to puberty, the susceptibility markedly decreases. Children of 
the so-called " lymphatic diathesis " are particularly vulnerable, as are those 
who have been weakened by previous diseases. 

Pathology. — The pathology is in the main that of the pseudomem- 
brane. This is a true coagulation necrosis, which may be situated upon 
the pharynx, nasopharynx, larynx, trachea, or bronchi. More rarely it is 
found upon the mucous membrane of the nose, conjunctiva, or vaginal 
membrane. The bacillus or its toxins circulating in the blood may produce 
myocardial changes of a fatty or degenerative nature. The cervical lymph 
nodes show a simple cell hyperplasia. The involvements of the lungs and 
kidneys must be regarded as complications. 

Symptomatology. — The symptoms differ as they are the results of 
a pure or a mixed infection, and as to the anatomical distribution of the 
pseudoniembrane. The mixed type is usually an association of the Klebs- 
Loemer bacillus with the streptococcus as in scarlatina. 

The general symptoms of any of the forms of diphtheria are dependent 
upon the degree of toxemia. The attack is usually ushered in with vomiting 
or a chill. There is no characteristic temperature curve. The fever is of a 
low grade, 101° to 102° F., in uncomplicated cases. The pulse rate is 
increased in direct proportion to the youthfulness of the patient. Lassitude 
or somnolence in various degrees may be observed before local lesions are 
suspected. The quantity of urine is diminished, and traces of albumin are 
found in a large proportion of the cases. The blood shows a hyperleuko- 
cytosis, especially in the polynuclear elements. The red blood-cells and the 
hemoglobin are correspondingly diminished. 

Diphtheria (Tonsillar and Pharyngeal). — In this type the clinical 
manifestations vary from those of an extremely mild variety to severe toxic 
cases. The child may not complain of any sore throat and the membrane 
may be found only on routine examination. On the other hand, there may 
be low fever, vomiting, and some difficulty in swallowing. Examination of 
the throat, which should always be done with the best possible light and 
with a curved tongue depressor, may show membrane in the form of a 
grayish-white patch on one or both tonsils. The tonsils may be enlarged 
and congested. The uvula or adjacent pharvnx soon become involved (see 
Plate XI). A grayer or dirtier colored membrance is seen after the third 
or fourth day. In severer cases the uvula, posterior pharynx, and fauces 
show the characteristic membrane. The general symptoms are now more 



240 DISEASES OF CHILDREN. 

aggravated, due to the toxemia, while prostration is marked. The glands 
of the neck enlarge and become painful. There is dysphagia and difficulty 
in enunciation, and there may be delirium. The breath is offensive and 
quite characteristic, with a pulse rapid and feeble. The temperature is 
irregular and at times high. If in this form we have the added complica- 
tion of a mixed infection, the toxemic symptoms are still further aggravated, 
becoming those of a true sepsis. Complications are then apt to supervene 
early, and the kidneys almost invariably suffer. 

Differential Diagnosis. — Tonsillar diphtheria must often be distin- 
guished from a follicular tonsillitis, especially if the exudation from the 
crypts has merged, and seemingly forms a membrane. This is especially 
necessary in the absence of a bacteriological diagnosis. (Plate XL) 

In follicular tonsillitis, both tonsils are usually involved simultaneously. 
There is an initial high temperature of 104° to 105° F. Usually there is 
no vomiting. Careful inspection will reveal isolated crypts distended with 
their cheesy detritus. The pseudomembrane can be readily removed. The 
diphtheritic membrane, on the other hand, adheres closely and leaves an 
excoriated and bleeding surface if forcible attempts are made to remove it. 
The bacteriological diagnosis should be made whenever feasible, but the 
returns should not be waited for except in extremely mild suspicious cases. 
The bacteriological examination may be made with a smear preparation 
stained with Loeffler's solution and directly examined, or by inoculating 
the tube of blood serum and examining the growth after twenty-four hours 
of incubation. The precaution should be observed to take the culture 
before any antiseptics have been applied, or at least within some hours 
thereafter. Schick has recently perfected a practical test which can be 
employed to separate the susceptible from the non-susceptible cases. A 
positive local reaction is obtained when a minute quantity of diphtheria 
toxin is injected under the skin, if antitoxin is absent, or present only in 
minute amounts. This reaction appears usually at the end of 24 to 48 
hours, persists from 7 to 10 days, leaving a small desquamating surface 
underneath which the skin remains pigmented. For technic, see article by 
Park and Zingher, X. Y. Eesearch Laboratory. 

Laryngeal Diphtheria. — In this form the membrane may extend 
from the nose or throat, or it may primarily involve the larynx. In the 
latter case there are symptoms due to congestion of the mucous membrane 
of the larynx and the vocal cords ; that is, a hoarse inspiratory cough, some 
restlessness and a low grade of temperature. Cultures, if taken at this 
stage, are usually found to be negative, especially if a laryngeal swab is not 
correctly used. As the disease progresses symptoms of obstruction are 



MIL-: INFECTIOUS DISEASES. 241 

apparent, due to the formation of the laryngeal membrane which is some- 
times visible about the epiglottis. The cough is more aggravated and 
paroxysmal in character; the patient acts as if attempting to dislodge an 
irritating foreign body. There is partial or complete aphonia with a muffled 
or suppressed cough and whispering voice. The accessory muscles of 
respiration are brought into requisition. The periods of remission from 
coughing become shorter and shorter in duration, and are easily brought on 
by disturbing the patient. If the child falls into a restless sleep, the symp- 
toms are lees noticeable, but do not in any sense resemble the normal. 

The pause between inspiration and expiration is noticeably prolonged. 
The supraclavicular, epigastric, and diaphragmatic spaces show marked 
recession at the height of inspiration. The mucous membranes and nails 
are cyanosed. I nless relief is now obtained, extreme restlessness sets in, 
and the child attempts in every way to get air; it is markedly cyanosed. a 
cold perspiration appears on the forehead, stupor supervenes with spasmodic 
breathing, apnea, and death. 

In certain cases the membrane may extend to the trachea, even beyond 
the bifurcation of the bronchial tube (see Fig. 67). 

The Heart in Diphtheria. — During the course of diphtheria, as well 
as throughout convalescence, the heart must be most carefully watched. 
When the local manifestation of the disease is slight and there is no sepsis, 
the heart may suffer comparatively little. There is a direct ratio between 
the amount and character of the local inflammatory process and the nature 
and severity of the constitutional symptoms, especially as regards the heart. 
In mild diphtheria, a moderately rapid or irregular pulse, without other 
constitutional symptoms, does not seem to porkmd the danger that the 
same action does in severe septic cases. Thus, in mild attacks, an irregular 
pulse during convalescence may sometimes be improved by letting the child 
get out of bed. An irregular or intermittent pulse, without symptoms of 
prostration, cannot have the same significance as when the two coexist. 
The septic type, with much glandular swelling in the neck, is often fatal 
from a persistent and powerfully depressant action upon the heart. This 
organ has here not only to contend with the toxins of diphtheria, but with 
a general septic poisoning as well, shown by extreme pallor, persistent 
vomiting and stupor. The occurrence of vomiting in connection with a 
weak pulse is here an exceedingly grave omen. The vomiting may take 
place before there are marked evidences of heart failure, but the latter will 
sor.n follow. If. in cases where the pulse is acting badly, vomiting begin-. 
the heart will usually prove intractable. A distinct and marked lowering 
of the pulse rate is sometimes noted in grave cases. This slowing may take 
16 



242 



DISEASES OF CHILDREN". 



place before or after a distinct quickening. The prognosis will depend 
upon the degree of slowness, which, if extreme, is always followed by a fatal 
ending. In a case treated by one of us, a boy of five years started with a 
rapid pulse, which slowed up until it was only 28 for two days before his 
death. Hypodermic stimulation by strychnin, camphor, cafTein and brandy 
is all that is available in these cases. When the heart is not acting well in 




Fig. 67. — Cast of the trachea and bronchi expelled from a case 
of laryngeal diphtheria. 



diphtheria, the patient must be kept very quiet in the recumbent posture 
until complete recovery takes place, otherwise sudden death may ensue even 
during convalescence, especially in septic cases. 

Differential Diagnosis. — .We have abandoned the term croup as 
applied to diphtheria, as it only tends to misleading conceptions, and per- 
haps to serious mistakes in management. Clinically, the diagnosis should 
be based upon the character of the cough, the aphonia, the muffled cry, the 
progressive signs of laryngeal obstruction, and the recession of the thoracic 
spaces. In non-diphtheritic laryngitis the child is taken suddenly ill at 
night with an attack of suffocation and a brassy, barking cough. Ordinary 
remedial measures, such as steam inhalations and emetics, give speedy 
relief, with the resumption of normal breathing and apparent health during 
the next twelve to twenty-four hours, when a second milder attack may 



THE INFECTIOUS DISEASES. 243 

supervene. Edema of the lungs, especially when it early complicates a 
bronchopneumonia, may simulate an attack of laryngeal diphtheria. The 
physical signs must be depended upon to clear up the diagnosis. 

Nasal Diphtheria. — This form is usually seen in children of the school 
age, and unfortunately the cases are not recognized and isolated as early as 
they should be. From a clinical standpoint the Schick reaction is particu- 
larly useful in the diagnosis of doubtful cases of nasal diphtheria to deter- 
mine whether they are true cases or simply carriers. The negative reac- 
tion excludes clinical diphtheria. Children with nasal diphtheria are 
undoubtedly great carriers and disseminators of the infection. The disease 
should be suspected in cases of intractable or aggravated rhinitis in which 
there is a mucopurulent, blood-tinged discharge, accompanied by evidences 
of nasal obstruction. The nostrils and upper lip are often excoriated. The 
children are not sick enough to want to go to bed and may have little or no 
fever. The use of the nasal speculum will often show the membrane in the 
nares. It is usually in shreddy patches rather than in firm membranous 
masses. The glands at the angle of the jaw are moderately enlarged. A 
culture should be made in all suspicious cases. 

If the posterior nares is involved by extension from the pharynx, the 
prognosis is graver, as it tends to lessen the respiratory ability and the 
willingness of the child to take food. The toxemia is likewise greater, and 
the cardiac muscle soon weakens. 

Conjunctival Diphtheria. — As in the other forms, this may be pri- 
mary or secondary to the disease of the nose or throat. The course is 
extremely rapid. There may be a profuse purulent discharge with marked 
edema of the eye-lid ; the conjunctiva is clouded with a thin membrane of a 
gray color which adheres closely and bleeds easily if attempts at removal 
are made. 

These local symptoms are accompanied by an increase in the tempera- 
ture, pulse rate and by somnolence due to the toxemia. 

Complications. — The respiratory tract, the nervous system and the 
heart are the greatest sufferers from the toxemia of diphtheria. Pneumonia 
is a frequent complication, especially in badly nourished children or in 
those that have been intubated. The mixed infections predispose to this 
complication, especially in those under two years of age. Postdiphtheritic 
paralysis occurs in about one-fifth to one-seventh of all cases. The common 
form is the local paralysis of the palatal group of muscles coming on early 
or late in convalescence. The symptoms are regurgitation of liquids through 
the nose, dvsphagia, and dysarthria. The uvula is found relaxed and not 
supported by its muscles. In the severer forms the physiological action of 



24A DISEASES OF CHILDREN. 

the pharynx and larynx is disturbed. The muscles of the lower extremities 
and the eye may be involved in the paralysis. The patellar reflexes are lost, 
and there may be anesthesia of the lower extremities. Only rarely is there 
paralysis of the upper extremity as a part of the general paralysis. If the 
branches of the vagus are involved cardiac irregularity is noticed, and vomit- 
ing and pains in the abdomen are complained of by older children. There 
is a tendency to sudden death in these cases. Nephritis occurs as a result 
of the toxemia and as it often appears insidiously without pumness or 
anasarca, the urine should be carefully watched. 

Prognosis. — This must be formed by a consideration of the patient's 
age, his resistance, the location of the membrane, whether of the pure or of 
the mixed type, and the time of the serum administration. The following 
are the mortality statistics from the Boston City Hospital: 

(Cases treated with antitoxin.) 
Under five years, 20 per cent, of all cases. 
Five to ten years. 8 per cent, of all cases. 
Ten to fifteen years, 3 per cent, of all cases. 

Exclusively nasal cases offer the best prognosis. Uncomplicated ton- 
sillar or pharyngeal cases rank next in a good prognosis. Laryngeal cases 
are the least favorable, especially when the necessity arises for intubation or 
tracheotomy. In private practice, where the circumstances are the most 
favorable, the mortality has been reduced to less than one-third of all cases. 
Antitoxin has been the means of reducing all the mortality statistics; and 
if given before the fourth day of the disease the prognosis is very favorably 
influenced. 

Treatment. — The management may be divided into the prophylactic, 
general, serum, local, and operative treatment. 

Prophylactic. — Immunization with antitoxin assumes the first place 
in prophylactic treatment. The immunity lasts from three to four weeks 
and, as conclusively proven by the statistics from the New York Board of 
Health and elsewhere, has saved many lives. Thirteen thousand persons 
received immunizing injections through the New York Department of 
Health ; of these only three-fourths of 1 per cent, had a subsequent mild 
grade of diphtheria, and there was only one death. Immunizing doses of 
500 to 1,000 units should be given to all the susceptible individuals in a 
family who have been exposed. In hospitals or institutions patients may 
he immunized, especially if measles are epidemic. All true cases and sus- 
pected cases should be carefully isolated, and disinfection practised as is 
indicated in the special article on this subject (page 300). (See Shick 
reaction, page 240.) 



THE INFECTIOUS DISEASES. 245 

General Treatment. — The child should be placed in bed in a well- 
ventilated, sunlit room, capable of separation from the rest of the house. 
Cool liquid or semisolid foods, such as milk, ice cream, junket, etc., should 
be offered at short intervals. Cold compresses are useful to mitigate the 
dysphagia, while light ice-bladders are often agreeable and efficacious when 
applied to the neck, particularly in glandular cases. The bowels should be 
kept open with calomel or salines. The urine should be examined at least 
bi-weekly. Strychnin sulphate in doses of from 1/240 to 1/100 of a grain, 
according to the age of the child and the necessity for stimulation, may be 
given every two to three hours. Whiskey may be alternated with the strych- 
nia in toxemic cases with irregular heart action or bradycardia. Small 
doses of morphine, 1/40 to 1/16 of a grain, are often efficacious in con- 
trolling the restlessness, and at the same time acting as a tonic to the heart. 
Infusions of normal saline solution have been of material assistance in sav- 
ing desperate cases. Bromid of sodium, if not contraindicated by the 
heart's action, is of value as an antispasmodic before extubation in laryn- 
geal cases. Paregoric or Dover's powder in small doses may be given for the 
same purpose. 

Serum Treatment. — Antitoxin should be given in all cases of diph- 
theria or those suspected of being diphtheritic. In its improved form there 
are no contraindications to its use. Three thousand units at least should 
be given in mild cases of faucial or nasal diphtheria, and repeated with a 
double dose in twenty-four hours if the false membrane has not shown signs 
of disappearing: 5,000 units may be the initial dose in severer cases. 
In laryngeal diphtheria 5,000 units in infants and 10,000 units in older 
children should be given at once. The dose should be repeated in twelve 
hours in cases of stenosis if the respiratory difficulty is not ameliorated. 
Double doses must be given if the disease is seen in its later stages. Immu- 
nization is satisfactorily accomplished with injections of 500 to 1,000 units, 
according to the age of the child. In very toxic cases of diphtheria the 
antitoxin should be injected intravenously in large doses. 

The loose tissues under the pectoral region or over the right or left 
iliac region may be selected for the site of the injection. The skin is made 
surgically clean, and the antitoxin injected with a large sterile syringe and 
needle. The wound should be sealed with collodion. The pseudomembrane 
after the injection of antitoxin slowly tends to detach itself. In laryngeal 
cases, in which the membrane is not seen, the decreasing symptoms of ob- 
struction give evidences of its good effects. The hypertrophied lymph 
nodes decrease in size, and the general symptoms are all improver!. An 
eruption in the form of an erythema or urticaria sometimes follows the 



246 



DISEASES OE CHILDREN. 



injection of antitoxin. This is attributable to the horse serum itself. A 
scarlatiniform or macular rash is occasionally observed. The improved 
concentrated preparations rarely produce skin manifestations. 

Local Treatment. — The curative effect of antitoxin has superseded 
the use of the strong antiseptics which were formerly locally applied to the 
membrane. In older children who can gargle, the use of a mild antiseptic 
solution, such as diluted Dobell's solution, listerine, or a common salt solu- 
tion, will assist in removing the loosened membrane. Younger children are 
markedly benefited by irrigations of salt solution, especially in nasal diph- 
theria (half a dram to the pint), used at a temperature between 100° F. 
and 115° F. An ordinary fountain bag is used, placed about two feet 




Fig. 68. — Position of the patient in intubation. 



above the patient's head, who lies on his side, prepared as for intubation 
(see Fig. 68). A small nozzle is then placed in one of the patient's nostrils 
and the water allowed to flow, with intermissions to allow for expulsion and 
breathing. If done in this way, the child soon becomes accustomed to the 
process and is not frightened, and much relief is obtained. In certain cases 
the nozzle may be inserted behind the back teeth, and the mouth thus irri- 
gated. If the bag is not placed too high the pressure will not be sufficient 
to carry infection through the Eustachian tube. 

An ice-bag applied to the neck in cases of tonsillar diphtheria affords 
relief and tends to inhibit the growth of the membrane, and to reduce the 
swollen lymph nodes. 



THE INFECTIOUS DISEASES. 



247 



Laryngeal cases are often relieved by swabbing away the collected 
material at the head of the tube, an ordinary laryngeal applicator being used 
for this purpose. Diphtheria affecting the conjunctiva must receive as close 
attention as a case of gonorrheal conjunctivitis besides the injection of 
large doses of antitoxin. 

Intubation. — Intubation, or the relief of laryngeal stenosis by the 
insertion of a tube, was perfected by Dr. Joseph O'Dwyer, of New York, in 
1883. The brilliant results obtained have brought this means of relief into 
universal favor almost to the exclusion of tracheotomy, which is now rarely 
practised. 




Fig. 69. — O'Dwyer's intubation instruments with detachable parts, 
in an aseptic case. 



The indications for performing intubation are as follows: Intubation 
should be performed in laryngeal diphtheria when there is marked dyspnea, 
restlessness, retraction of the epigastric and supraclavicular spaces with 
evidences of cyanosis. 

The child is prepared by being closely wrapped and pinned in a sheet 
(Fig. 68). The operation may be performed in a horizontal position on a 
table or in an upright position with the child's head resting against an 
assistant's shoulder. A second assistant is required to hold the head in the 
median line and to keep the mouth gag in place, as rapidity and a certain 



248 



DISEASES OF CHILDREN. 



amount of dexterity are necessary. Practice upon the cadaver, and if pos- 
sible upon the living subject, should be had under the instruction of an 
experienced operator. The instruments used are generally those of the 
O'Dwyer pattern, as they conform most accurately to the anatomy of the 
region. They are now made of hard rubber, metal lined, in sizes according 
to the age of the child. The neck of the tube is held within the vocal cords, 
while its lower end extends almost to the bifurcation of the trachea. 




Fig. 70. — Introducer, with obturator and tube in place. 



An introducer, an extubator, the tubes, a mouth gag and scale complete 
the set. 

The proper tube having been selected, a loop is made by threading a 
piece of strong silk through the eyelet placed in one side of its head. The 
child's head is firmly held and its extremities kept from moving by a second 
assistant when on a table, or by the knees of the assistant who holds the 
patient in his lap. The left index-finger is inserted and the epiglottis 
found and firmly held forward. The palmar surface of the finger should 




be presented to the tube. At first the handle of the introducer is held 
parallel to the child's body; it is then raised until the tube passes between 
the vocal cords, when it will be beyond a right angle to the body of the child. 
The trigger of the introducer is now used, which allows the body of the 
tube to pass well beyond the vocal cords, the finger at the head of the tube 
gently forcing it into place while the obturator is being removed. The 



THE INFECTIOUS DISEASES. 



249 



cord is still kept in place, but the mouth gag should be quickly removed. 
A metallic cough and the relief of the symptoms of stenosis will be the 
proof of success. A series of expulsive efforts, followed by free inspiratory 
effort, disappearance of cyanosis, and a period of calm and rest for the 
child, will follow. 

Failure may result because the operator has not kept closely to the 
dorsum of the tongue in passing his tube, or because he has failed to keep 
the handle of his instrument parallel to the child's body in the first move- 
ment toward the epiglottis. In rare instances a certain amount of mem- 
brane is pushed down before the tube, and as a result there is no relief, or 
there may be an increase in the stenotic symptoms. The child should then 




i n m 

Fig. 72. — Intubation tubes. I. Granulation or built-up tubes : II, ordinary 
tube (lateral view) ; III, ordinary tube (front view). 

be held in an inverted position, when the membrane usually is expelled, 
and the tube may then be reinserted. If any force is used damage may be 
done. The cord may be removed after some minutes by placing the finger 
on the head of the tube and withdrawing it, or it may be fastened on the 
side of the face with adhesive plaster. 

Extubation. — This should be performed as soon as there are evidences 
of marked improvement in the general condition of the patient as shown by 
decreased toxic symptoms, and a marked decrease in the laryngeal obstruc- 
tion. This may occur on the third, fifth, or seventh day, depending upon 
the severity of the case, upon the early use of the antitoxin, and upon the 
age of the child. Children under two years of age cannot, as a rule, be 
extubated as soon as older children. 

If cyanosis follows the removal of the tube, it must be quickly replaced, 
all the preparations having been made for this possibility. Special tubes 



250 



DISEASES OF CHILDREN. 



with built-up heads and retention swells are used in cases demanding pro- 
longed intubation ( Fig. 72 ) . They act by preventing and causing destruc- 
tion of the granulation tissue. 

The Feeding of Intubated Cases. — Older children soon manage to 
take fluids and semifluids without much difficulty. Infants and younger 
children may be fed in a prone position, or with the head lower than the 




Fig. 73. — Extubation. 



body, being fed, if necessary, by a bottle or medicine dropper for a few 
days. Feeding by gavage may occasionally be necessary. 



Tracheotomy. 
Indications for Tracheotomy. — Tracheotomy should be performed in 
those cases in which intubation has failed and the membranes are forced 
further down into the larynx ; in cases in which the membrane forms below 
the tube and no relief is obtained ; and in cases of edema of the glottis in 
which there is extensive infiltration. 



THE INFECTIOUS DISEASES. 251 

It may here be mentioned that intubation is far preferable to trach- 
eotomy, and the latter operation should be performed only as a last resort 
or in those rare cases in which a proper tube is not retained. 

The operation should be performed, if possible, under a light general 
anesthetic. The patient should be prepared as for any aseptic operation if 
the circumstances allow, the neck being extended over a sand-bag and kept 
in the median line. An incision one to one and a half inches long is made 
through the subcutaneous tissue, and then the facia and sternohyoid muscles 
are separated. The engorged venus plexus is pushed to one side and the 
trachea exposed. By means of a bistoury an opening is made sufficiently 
large to admit the cannula. (An instrument which Avill at once incise and 
dilate the tracheal wound is now on the market.) 

When free respiration is established, the cannula is fastened in place 
by tapes about the neck, and the wound dressed with moist gauze. A steam 
atomizer to moisten the respired air is helpful. The attendant should dili- 
gently remove the tracheal secretions deposited upon the pledgets of mois- 
tened gauze. The inner tube of the cannula should be removed and thor- 
oughly cleansed three or four times a day, or whenever it is obstructed. 
After the third or fourth day an attempt may be made to permanently 
remove the cannula. If the patient can get along without, the tube, the 
wound is cleansed, dressed, and allowed to heal. 



Pertussis. 

(Whooping-cough.) 

Pertussis is an acute infectious disease characterized by a paroxysmal 
cough that consists of repeated expirations ending in an inspiratory whoop, 
which is often followed by vomiting. Owing to its complications it must 
be classed as one of the dangerous diseases of early life. 

Etiology. — The Bordet-Gengou bacillus is now generally accepted as 
the specific organism. The secretion is apparently the means of transmission 
from one individual to another and is very communicable. Clothing and 
the rooms of the patient do not seem to carry or retain the infective agent. 
Sporadic cases are constantly seen in large centers, and epidemics frequently 
occur both in urban and in rural districts. Whooping-cough is no respector 
of age. It has occurred in the newly-born and in well-advanced adult life. 
The period of incubation is from seven to fourteen days. The primary stage 
is probably the time of greatest rlanger to others. 



252 DISEASES OF CHILDREN. 

Pathology. — The larynx and trachea show a marked congestion and 
exudative inflammation of their mucous membrane. In fatal cases, areas 
of emphysematous lung are commonly found. Subconjunctival hemor- 
rhages occur in severe cases, and cerebral hemorrhages have been found. 

Symptomatology. — For purposes of convenience in description, the 
disease may be divided into three stages. Namely, the primary (in which 
the mucous membranes of the nose, larynx and trachea are inflamed), the 
spasmodic stage, and the period of recession. These, however, merge into 
each other and are not sharply defined. 

Primary Stage. — The exposed child, after a varying period from two 
days to two weeks, may have suffused eyes, a rhinitis, and a congestion of 
the pharynx on examination. The child does not feel sick, but coughs 
severely, especially at night. The cough is described as having a croupy 
character. After a few days it becomes more pronounced at night and 
more frequent in the day time. Physical examination at this time may 
give no evidences of bronchitis if this is suspected. These negative signs 
are valuable in leading to the true diagnosis. An increase in the mono- 
nuclear leukocytes is quite frequently found at this time. A tongue 
depressor irritating the pharynx will sometimes produce the characteristic 
whoop, and thus confirm the diagnosis. A rise of one or two degrees 
of temperature is sometimes observed, especially when there is an 
accompanying bronchitis. 

Spasmodic Stage. — This is so named because of the paroxysmal cough 
or whoop which follows the several expiratory efforts. The child realizing 
the approach of a paroxysm, seeks support from its attendant or clings to 
some article of furniture. There are three or four violent expiratory 
efforts, followed by a period of apnea, and then the tremendous inspiratory 
effort is made which, entering through a partially closed glottis, causes the 
so-called whoop. During this effort the eyes have become congested, the 
face almost cyanosed, mucus streams from the nostrils, and a mass of 
mucopurulent secretion follows the whoop. Vomiting occurs if there is any 
food in the stomach. Relief now comes to the exhausted patient, and after 
a brief period of rest, during which there is sweating of the forehead and 
face, the child goes back to its play. These attacks may occur ten or even 
a hundred times a day. Naturally, the nutrition soon suffers; the face may 
later become edematous or puffy, masking the malnutrition of the body. 
Severe cases may have subconjunctival hemorrhages or bleeding from the 
nose or lungs. The urine may show traces of albumin and hyalin casts. 
Convulsions sometimes follow an exceptionally severe paroxysm, especially 
in infancy. In young infants the spasmodic stage begins very soon after 
the beginning of the attack and the " whoop " may be absent. 



THE INFECTIOUS DISEASES. 253 

Recession of symptoms is shown by a decrease in the number and 
severity of the paroxysms, ending in a cough which persists for several 
weeks. 

Complications. — Bronchopneumonia frequently complicates pertussis, 
especially in infancy. This is the result of an infective process made pos- 
sible by the abnormal condition of the bronchial tubes and the lowered vital 
resistance. It generally occurs at the end of the paroxysmal stage. Bron- 
chitis and emphysema are complications more frequently seen in older chil- 
dren. Tuberculosis not infrequently follows in the wake of pertussis. It 
may be localized (from latent bronchial lymph nodes) or even a general 
miliary tuberculosis may result. Severe attacks of vomiting reduce the 
general nutrition and predispose to more important complications. Con- 
vulsions result from congestion of the brain, or from minute capillary hem- 
orrhages which may occur during the paroxysm. We have seen hemiplegia 
follow a severe paroxysm. Hemorrhages into the conjunctiva and hernias 
in various parts of the body also result from the severe strain imposed by 
the paroxysms. 

Course and Prognosis. — In some cases the disease lasts only a week 
or two. but on the other hand, we have seen it persist beyond three months. 
If complications occur it is more apt to be prolonged. The mortality of 
this disease and its complications is higher than is generally appreciated. 
Infants, especially, are prone to fatal attacks of pneumonia, convulsions, and 
tuberculosis. Among the poor, where undernourished children are most 
likelv to be found, the mortality is high. 



1910 

1911 

1912 



C.5E5 2018E 

Deaths 2941 



a*s 3210 [ 

Deaths 3841 



as^s 2132 [ 
1)eaths 2871 



IQIO OSES 3?29( 



Deaths 420HI 

The prognosis is based upon the general condition of the child, the 
number and character of the daily paroxysms, and its ability to retain food. 

Treatment. — Although whooping-cough, like the other infectious dis- 
eases, is self-limited, its severity can be considerably modified and its com- 
plications often prevented by appropriate treatment. 



254 



DISEASES OF CHILDREN". 



Aerotherapy. — The child should spend the greater part of the day 
out of doors in pleasant weather. If the circumstances permit removal to 
the seashore it is of undoubted benefit. The fine saline particles thrown 
up by the surf give quick relief by being inhaled. The sleeping-quarters 
should also be well ventilated. 

Drugs. — For the control of the cough early in the spasmodic stage we 
have had very satisfactory results with the three following drugs: fluoro- 
form, the bromids, and antipyrin. The treatment may be begun by giving 
two drops of a 2.8 per cent, solution of fluoroform every two hours during 
the day to a year-old child. The dose may be increased by two drops for 
each succeeding year of age. Occasionally this is not effectual enough, or 
apparently the child becomes accustomed to its sedative action. The bromid 
of soda in two-grain doses every three hours for a two-year-old child may be 




Fig. 74. — The Kilmer belt for pertussis. 

substituted. Antipyrin is well tolerated, and can safely be prescribed 
if complications do not contraindicate. It may also be combined with the 
bromids as in the prescription given below. A child of six months can be 
given J grain of antipyrin at three-hour intervals, 2 grains to a two-year-old 
child. If it is used with the bromids the dosage must be regulated accord- 
ingly. 

In exceptional instances in which the paroxysms are particularly severe 
and are preventing rest, small doses of heroin, as indicated in the prescrip- 
tion below, will give relief for the night. 



For a two-year-old child : 

Ifc Antipyrini gr. xxxij 

Glycerini 3iij 

Aquse q. s. ad. §ij 

Misce et signa.- — ■ One teaspoonful every three hours for six 
doses. 

B Sodii bromidi gr. xlv 

Antipyrini gr-. xxiv 

Glycerini 3iij 

Aquae q. s. ad. §ij 

Misce et signa. — One teaspoonful every three hours for a 
three-year-old child — well diluted. 



THE INFECTIOUS DISEASES. 255 

R Heroini hydrochloridi gr. g 

Autipyrini gr. xvj 

Elixiris adjuvantis 5U 

Misce et signa. — A teaspoonful every three hours to a child 
of two years for three doses. 

Vaccine Treatment. — A study of the literature, coupled with our own 
experience, make it impossible to advocate this form of treatment in per- 
tussis. 

Diet. — Food should be taken in smaller quantities and at lessened 
intervals than in health. This measure in itself prevents the vomiting 
which readily occurs when a full meal is taken. After vomiting, a cup of 
milk or meat broth may be immediately given. Only simple, light and 
nutritious articles should be permitted in the dietary. 

The inhalation of antiseptics has given us no satisfactory results. In 
fact, it tends to encourage poor ventilation in the sleeping apartment. A 
belt as suggested by Kilmer can be worn if vomiting is frequent. In a cer- 
tain number of cases this appliance (see Fig. 74) has given relief from 
this distressing symptom. 

Mumps. 
(Epidemic Parotitis.) 

Mumps is an acute communicable disease of the salivary glands, char- 
acterized by a swelling of the parotid gland and the neighboring salivary 
glands, and at times involving the testis or ovary. 

Etiology. — Children from two to fifteen years of age are most often 
affected. Epidemics are common in schools and institutions. The specific 
contagium has not been isolated. Close contact is necessary for its dis- 
semination, but the disease is transmissible before the swelling appears. 
The portal of entry seems to be the buccal cavity. The period of incuba- 
tion is an indeterminate one ; it ranges from one to four weeks. Immunity 
is generally conferred by the one attack. Recurrences, however, do occur. 

Pathology. — According to Virchow, there is an inflammatory, serous 
and cellular infiltration of the intraacinous and periacinous connective 
tissue, which tends to resolution without induration. 

Symptomatology. — In children the onset is usually mild, with a 
period of malaise, drowsiness, fever of one or two degrees (only rarely 
104° F.), chilliness, and sometimes vomiting. A swelling now appears 
below the lobe of the ear on one side of the face and in a few days the 
opposite gland is generally involved. The child complains of a feeling of 
fullness, with pain localized in the angle of the jaw. The swellings are 
elastic on palpation. Mastication is difficult and food may be refused for 
this cause. The fever ranges from 101° to 103° F. Occasionally' there is 
earache or deafness. The swelling may extend over the parotid in front, 



25G DISEASES OF CHILDREN. 

or involve the submaxillary gland and the neighboring lymph nodes, giving 
the characteristic rounded appearance. The displacement of the auricular 
lobule with the lobe of the ear in the center of the swelling assists in fixing 
the diagnosis. 

In some instances there is little or no discomfort, and the child is not 
willing to go to bed. After seven or ten days the swelling subsides and 
entirely disappears. Relapses, however, may occur. Occasionally the 
swelling is very large and painful. In exceptional instances only, the 
submaxillary glands may alone be involved. 

Lymphocytosis is quite a constant accompaniment, especially at puberty 
(Wile). 

Complications. — In boys orchitis is occasionally seen, and the same 
may be said of ovarian pain in girls. The breasts especially in girls may 
be tender. When these complications do occur, the child is generally at or 
near the age of puberty. The lymph nodes may become secondarily in- 
volved, and suppuration of the affected glands take place, but only if there 
has been a mixed infection. Deafness, inflammatory eye diseases and rarely 
nephritis are complications which may occur, and should be guarded 
against. 

Differential Diagnosis. — Mumps should not be confounded with 
hypertrophied lymph nodes which present an irregular nodular swelling 
and are not found on the face. An examination of the throat or a con- 
comitant infectious disease may account for such a swelling. Involvement 
of the submaxillary glands alone, so-called submaxillary mumps, must, 
however, be considered. If with a history of exposure there is a large soft 
swelling filling up the space between the angle of the jaw and the mastoid 
process, and it lifts forward the lobe of the ear, the diagnosis is quite 
certain. 

Prognosis. — In this benign disease, which is rarely complicated, fatal- 
ities do not occur, and the prognosis is most favorable. Deafness some- 
times results and rarely following an orchitis the testicle ceases to develop. 

Treatment. — As it is a communicable disease, the children should be 
isolated. If there is fever and discomfort, a laxative is given, and the 
child is put to bed. Local anodyne applications of 3 per cent, ichthyol- 
lanolin ointment, or warm oil of hyoscyamus are applied. Often a hot- 
water bag is found to be very agreeable. Mouth-washes of listerin or boric 
acid solution should be used frequently. The bowels should be kept freely 
opened, and a liquid or soft diet ordered. Guaiacol ointment (5 to 10 per 
cent.) is soothing if orchitis is present as a complication. The patient may 
minerle with other children after the third week. 



THE INFECTIOUS DISEASES. 



2o 



The question often arises, when may a child who suffered from a recent 
infection return to school or mingle with other children? The following 
suggestive table mav here be of service : 



!lf Other Children Are T - rM _.„ 
After an Attack a Pupil at Once Removed If Other Children Re- 
Mav Not Return to from House Thev n l a r in m House They 

School Until May Return to Ma £ not Return to 

School School Until 



DISEASE. 



Scarlet Fever 



After 6 weeks from in- 
ception of disease, 
provided desquama- 
tion is complete and 
no aural discharge is 
present. 



14 days after 
disinfection 
tire change 
ing. 



thorough 10 days after certificate 
and en- by Board of Health, 
of cloth- 



Diphtheria After 3 negative throat? days after immuniza- 1 week after certificate 

cultures taken on tion and 3 negative from Board of 

I different days. cultures. Health after immun- 

izing. 



Measles 3 weeks after appear- 3 weeks after last ex- 10 days after certifi 



ance of rash and un- 
til all symptoms have 
disappeared. 



German Measles. . 3 



weeks after appear- 
ance of rash and un- 
til all symptoms have 
disappeared. 



posure. 



cate from Board 
Health. 



of 



After 2 weeks. 



2 weeks after certifi- 
cate from Board of 
Health. 



Chicken Fox After complete healing 18 days after last ex- 1 week after last case 

of all scars. posure. has been thoroughly 

healed and disiri- 
: fected. 



Mumps 



1 week after the swell- 
ing has entirely sub- 
sided. 



\fter 3 weeks from in- 2 weeks after subsid- 
ception of primary ence of last case, 
case. 

Whooping Cough. . 3 weeks after last IS days after last ex- IS days after all cough 
characteristic cough. posure if no cough [ has ceased in the 

last case. 



Conjunctivitis 



days after all inflam- After use of disinfect- After use of disinfect- 
mation has disap- inu eye drops. ing eye drops, 

peared and a negative 
smear is obtained. 



Colds, with nasal 

discharge All symptoms of dis- 
charge have ceased. 



In ease of influenzal 
attack disinfect 
premises before re- 
turning to school. 



17 



258 DISEASES OF CHILDREN. 

Typhoid Fever. 

Etiology. — Typhoid fever is a specific infectious disease due to the 
typhoid bacillus. Infected drinking-water, infected milk, and contact with 
attendants who may be typhoid bacilli carriers are in greater part respon- 
sible for the infection in children. Irresponsible children are liable to 
drink contaminated water in any place, and especially when going about at 
summer resorts. Infants and young children are more liable to infection 
when they are placed close to the ground or are handled and fondled by 
many adults. Dishes, thermometers, or flies may carry the infective agent. 
The fall of the year, when the children return from the country, always 
shows the greatest number of cases. The disease is by no means as rare in 
infants and children as was formerly supposed. The Widal reaction has 
revised the figures. About 6 per cent, of the cases occur under two years, 
and 8 per cent, under five years, and 46 per cent, between five and fifteen 
years. Typhoid fever may be transmitted from the mother to the fetus. 

Pathology. — As differentiated from the pathology of the disease in 
adults, we have a milder ulceration of the solitary follicles and Peyer's 
patches ; and when*examined postmortem, it is often difficult to distinguish 
the ulceration from a case of ileocolitis. In infants there may be no ulcer- 
ation whatever. In older children, especially where healing has taken place, 
the " shaven beard " appearance is sometimes seen due to pigmentation. 
The ulceration rarely penetrates beyond the submucosa. This pathologic 
picture is in distinct relation to the milder character of the symptoms as 
met with in children. The mesenteric lymph nodes in the ileocecal region 
are enlarged. The spleen may be enlarged, congested, and soft. The 
mucous membrane of the bronchi and larynx are often involved in varying 
grades of inflammation. The kidneys quite regularly show cloudy swelling. 
The heart muscle shows mild, grades of myocardial degeneration. 

Symptomatology. — The prodromal symptoms are so irregular and 
so apt to be influenced by some one prominent symptom or symptom- 
complex as to lead the examiner astray. 

In infants the mode of onset is quite different from that of older 
children. The infant has an initial high fever which becomes irregular 
or remittent, and subsequently the symptoms resemble a gastroenteric 
infection. Convulsions are the exception. Older children who are able to 
describe their symptoms complain of headache and chilliness. Malaise and 
vomiting are frequently observed, while delirium at night, when the fever 
is high, is seen after a few days. Epistaxis is the exception. Cerebral 
symptoms may usher in the disease. A cough is often present quite early 
and serves to obscure the diagnosis. A careful physical examination of 



THE INFECTIOUS DISEASES. 259 

the chest by a process of exclusion may point the way to an early diagnosis. 
It will be well to take up the symptoms seriatim to give a picture of the 
varied manifestations of the disease, and these will be described in the 
order of their early assistance in diagnosis. 

Roseola. — These spots, which are macules fading on pressure and 
distinctly discrete, are observed in more than 60 per cent, of the cases. 
The eruption is seen as early as the fourth or fifth day, and, as a rule, is 
widely scattered. The abdomen, chest, and back may each show them. 
We have seen hemorrhagic areas on the abdomen, toes, and heels in severe 
or fatal cases. 

Spleen. — As a rule, the younger the child the less often is the en- 
largement felt early. It is distinctly palpable in the second week. The 
splenic enlargement often persists after convalescence has begun. There 
may be a relapse without an enlargement of the spleen, or the spleen may 
not be felt throughout the course. 

Mouth. — The rather characteristic tongue seen in adults is rarely 
observed in children, and it clears up much more rapidly. Sordes on the 
lips are common. 

The Stools. — These are not necessarily of the pea-soup variety ; in 
fact, moderate constipation more often persists throughout the disease. 

The Temperature. — The temperature curve is only rarely typical. 
During the first week there is a gradual rise in temperature until the max- 
imum point is reached. The fever now assumes a remittent type, but it 
is not unusual to have intermissions. Cases with cerebral symptoms may 
have a hyperpyrexia for days. 

The temperature curve may last from two to six weeks ; occasionally in 
protracted cases there is a gradual daily rise ; but we feel that this fever 
may be solely due to the asthenia caused by a low diet. Complications 
such as bronchitis, pneumonia, otitis, or even constipation may influence 
the course of the pyrexia causing irregularities in the curve. Relapses pro- 
duce a low-grade temperature after a period of normal or almost normal 
temperature. 

Laboratory Tests. — An early test and one which often gives results 
during the first week is the use of blood cultures made from freshly drawn 
blood. The Widal reaction (see p. 56) is present in 95 per cent, of typhoid 
patient?, and may be obtained as early as the end of the first week. 

The urine and feces contain the bacilli, and improved laboratory meth- 
ods show their presence in 20 to 50 per cent, of the cases. The Ehrlich- 
Diazo reaction is sometimes present before the Widal reaction, and when 
obtained is confirmatory evidence of the disease, but not pathognomic 



260 DISEASES OF CHILDREN. 

The Blood. — The red blood-cells and the hemoglobin diminish as the 
disease progresses, but the leukocytes are quite uniformly low from the 
beginning. With the establishment of convalescence, the differential count 
shows an increase in the eosinophiles and mononuclear lymphocytes and 
a corresponding decrease in the polynuclear neutrophiles. 

Pulse. — The relatively slow pulse is obtained only in older children, 
from ten to fifteen years. Infants and young children not uncommonly 
have a pulse rate as high as 150. Irregularity is quite frequently noted, 
while the dicrotic pulse is rare. 

Pain. — It is seldom that this symptom is elicited in young subjects. 
In older children it is present in the ileocecal region in a good number of 
cases, and usually is accompanied by tympanites and probably is a result 
of ulcerative processes in the agminate glands or Peyer's patches. 

Hemorrhages. — It is rare to have hemorrhages in children. When 
they occur the amount is usually small and more easily controlled. 

The Heart. — Depending upon the amount of toxemia we have myo- 
cardial changes which may produce systolic murmurs and cardiac irregu- 
larities. 

Treatment. Prophylactic. — If children live in vicinities having a 
suspected water supply, or remove to such a locality, precautions should be 
taken to boil the water and to supply an absolutely clean, uncontaminated 
milk. The excreta of the attendants should be examined for the possibility 
of the presence of the bacilli if there has been a history of previous 
typhoid. Weaning or a wet-nurse is indicated if the mother herself is 
infected. 

Typhoid precautions should be scrupulously observed even in suspected 
cases, the feces, urine, and clothing being disinfected with carbolic acid 
or chlorinated lime (as given on page 301). The napkins of infants should 
be made of cheap material and destroyed by burning. Pishes and other 
washable articles should be sterilized by boiling. 

Acquired Immunity. — Further experimentation has established the 
value of typhoid immunization incorrectly spoken of as typhoid vaccination, 
and children may be thus protected, especially if they are to live or travel 
in a section having typhoid outbreaks or poor sanitary laws. 

Dosage for Typhoid Immunity.— For adults 500,000,000 bacilli 
are advised for the first dose and one billion for the second and third doses. 
For children the dosage may be gauged according to body weight; thus a 
child of 50 pounds will require one-half that of the adult. It is best given 
in the upper arm and the subsequent two doses given at ten-day intervals. 



THE INFECTIOUS DISEASES. 261 

General Treatment. — Careful, capable nursing far exceeds the value 
of drugs in this disease. A well-kept chart recording the variations in 
temperature, pulse, and respirations, every three or four hours, with notes 
upon the character of the pulse and stools, is of great importance to the 
physician. 

The room should be as large as possible and one that can be well aired, 
and in which quiet can be maintained. Two beds so as to allow ready 
change of linen and position are preferable. Scrupulous attention should 
be paid to the mouth, tongue, and teeth, keeping them as free as possible 
from foreign material by the use of swabs dipped in mild antiseptic solu- 
tions, such as listerin or boracic acid. For disinfection of excreta, see 
Disinfection (p. 300). 

Feeding. — In mild cases in which the temperature is not high, and 
the digestive processes have been little interfered with, milk and lime-water, 
thin gruels, plain or dextrinized, broths made of mutton or chicken, 
orangeade, and lemonade, form a list which will not be tiresome and which 
furthermore will fairly well keep up the patient's nutrition until he is able 
to take semisolid food in the beginning of convalescence. 

Severe cases with continued high temperature may require the pepton- 
ization of the milk or the discontinuance of milk entirely, if it causes 
tympanites. Dextrinized gruels, beef broths, and albumin water may be 
substituted. 

In convalescence, in addition to articles already permitted, zweiback 
dipped in broths, milk toast, junket, scraped beef, baked custards, and 
soft-boiled eggs are cautiously added to the diet. Matzoon and kumyss or 
home-prepared buttermilk are occasionally relished by the child and vary 
the monotony of his restricted dietary. In 11 consecutive cases in our 
hospital, 7 gained in weight, 3 lost slightly and 1 showed a considerable 
loss on the regular soft diet. 

Hydrotherapy. — The fever is in nearly all cases effectively controlled 
by sponging with alcohol and tepid water. We have discontinued the use 
of tubbing. Any good effects of the reduction of temperature obtained are 
more than counterbalanced by the nervous excitement it produces. 
Therefore, a wet pack is preferable for high temperatures not controlled 
by sponging, the sheets being wrung out in water at 90° F. If at this 
temperature a satisfactory reduction is not obtained, the wrappings may 
be sprinkled with water at 85° or even 80° F. An ice-bag may be applied 
to the head, especially if. there is headache or delirium, but it requires con- 



262 DISEASES OF CHILDREN. 

stant vigilance on the part of the nurse who should be instructed to remove 
it if any cyanosis develops. 

Drugs. — With the exception of certain symptoms which will require 
control by the use of medication, no drugs should be given. Intestinal 
antiseptics and alcohol as routine measures are to be deprecated. The 
bowels are kept open with saline enemas which may be given cool if the 
temperature is high. Divided doses of calomel are indicated in the begin- 
ning of the disease. Tympanites should be prevented rather than treated 
by careful supervision of offending articles of diet, especially the milk. 
Headache and restlessness if not sufficiently allayed by the hydrotherapeutic 
measures can be subdued by the use of the bromides. Alcohol is given in 
the form of sherry wine or whiskey if the pulse is weak or the reaction is 
not good following a pack. Strychnia, grains 1/200, tincture of digitalis 
or strophanthus, in two-minum doses, or brandy hypodermatically are given 
if collapse threatens. If hemorrhage occurs, a light ice bag or coil is im- 
mediately applied to the abdomen and Dover's powder in maximum doses 
given. The treatment for perforation, which would be evidenced by sudden 
pain, abdominal tenderness, and changes in the rational signs, demands 
prompt surgical intervention. 

Influenza. 

(Acute Catarrhal Fever. La Grippe.) 

Definition. — An acute, specific, infectious disease affecting the res- 
piratory or gastrointestinal tracts, and usually associated with marked pros- 
tration. 

Etiology. — While the disease is endemic, especially in damp, cold 
weather, it is very frequently seen in epidemic form. The immediate cause 
is a small bacillus first isolated by Pfeiffer in 1892. The bacillus may be 
localized in the mucous membrane of the nose, throat, or lungs. Other 
pyogenic bacteria may be present with the influenza bacillus, thus giving 
a mixed infection. Pfeiffer's bacillus resembles a diplocooccus, having 
rounded extremities and staining markedly at the ends. 

Incubation. — From twelve hours to three days. 

Pathology. — There is some inflammation in nearly all the mucous 
membranes. In addition to this, complicating inflammations may exist in 
the heart, lungs, middle ear, mastoid process, kidneys, and gastrointestinal 
tracts. Meningitis occurs, though not commonly, which can be proven by 
examination of the cerebrospinal fluid to be caused by the influenza bacillus. 
Tuberculosis may also follow an attack of influenza. A marked general 



THE INFECTIOUS DISEASES. 263 

depression often accompanying influenza is doubtless caused by the toxins 
secreted by Pfeiffer's bacillus. 

Symptomatology. — Although young infants are not particularly sus- 
ceptible in contracting the disease, yet when they are attacked it is apt to 
assume a grave form with high temperature and great prostration. The 
younger the child, the more severe is usually the infection. In older 
children the average clinical description of symptoms as affecting princi- 
pally either the respiratory, digestive, or nervous systems will hold good. 
It is true, however, that these varying symptoms will often be found com- 
bined in a given case. 

Inflammatory disturbances of the respiratory tract predominate in 
children. There is marked coryza with an acrid discharge that may ex- 
coriate the upper lip. A general pharyngitis is also present, the mucous 
membrane presenting a thickened, spongy appearance. The tonsils may be 
swollen and show white points of exudation in the crypts. In a word, there 
is a severe general rhinopharyngitis present that is prone to involve the 
Eustachian tubes and middle ear, with a secondary enlargement of the lymph 
notes that are connected with this region under the ear and back of the 
jaw. 

These disturbances are evidently more virulent than the ordinary in- 
flammation met with in this region. This is not only seen locally, but in 
the disposition of the process to extend downward. In some ways this is 
analogous to the course of measles. The larynx, trachea, and bronchi are 
quickly involved, but in many cases the inflammation does not extend 
below the larger or medium-sized tubes. The cough may assume a 
paroxysmal character simulating pertussis. In others there is involvment 
of the small tubes and alveoli coming on soon after the onset of the disease. 
This type of bronchopneumonia is much like the ordinary form so far as 
physical signs are concerned, but early prostration is more marked and the 
temperature is usually irregular and higher than the local lesion would 
seem to warrant. True lobar pneumonia is also not infrequently seen, and, 
as in most influenza conditions, exhibits disturbances of temperature and 
circulatory and nervous depression out of proportion to what would be ex- 
pected from the pulmonary signs. Perhaps the most frequent exhibition 
of pneumonia is seen in the form of irregular patches with sneaking in- 
vasion, when it is very difficult to decide the exact nature of the pneumonic 
process. 

Various grades of pleurisy are frequent accompaniments of pneumonia, 
and empyema may be the terminal condition. This must be constantly 
borne in mind as this empyema is even more insidious than usual, especially 
in infants. 



264 DISEASES OF CHILDREN. 

In cases where the gastrointestinal symptoms predominate there may 
be severe vomiting and the passage of loose, undigested stools. Nourish- 
ment is badly taken and after an interval the stools may contain mucus 
and even blood. The gastroenteric symptoms may appear at the very 
beginning of the attack, or later during the course of the disease. While 
under proper dietetic and medicinal treatment these symptoms may not last 
beyond a few days, they naturally add to the prostration, and in young and 
feeble infants may predispose to a fatal ending. 

The cases in which pure nervous disturbances preponderate over the 
inflammatory symptoms do not seem to be so common in early life. Some 
severe cases may start with convulsions and simulate meningitis with 
photophobia, stupor, and, in older children, headache and delirium. In 
uncomplicated cases, however, these marked nervous disturbances do not 
last longer than a few days. True cerebral meningitis may be caused by 
the influenza bacillus. AVe have seen a number of cases which clinically 
resembled cerebrospinal meningitis. The fluid from these did not show 
the presence of meningococcus or pneumococcus. In such cases closer 
study should be made of the fluid for the bacillus of Pfeiffer. 

Some of the clinical phenomena, aside from the types just mentioned, 
may be noted. The fever is apt to be irregular and at times very high, 
especially in young infants. In some cases, fever and prostration will be 
the principal symptoms of the disease with little evidence of any local in- 
flammation. In other cases, an irregular fever may last for several weeks 
and simulate typhoid fever. Here all the modern diagnostic methods must 
be employed in order to make a proper diagnosis. A further confusion will 
be caused by intestinal and diarrheal symptoms sometimes accompanying 
these prolonged cases. Some of the protracted cases are quickly relieved 
by change of air, particularly to a location where influenza is not so 
prevalent. 

The skin is sometimes involved, with various forms of erythema. This 
may at times simulate measles or appear in scarlet form. The irregular 
character and distribution of the eruption, with entire absence of desquama- 
tion, and existing in connection with the various symptoms of influenza will 
throw light on its character. 

The urine will frequently show traces of albumin in influenza. It is 
probable that this has no great significance. Cases have been reported in 
which acute nephritis has supervened. Eachford states that if nephritis 
exists as part of the influenza attack the worse symptoms occur early, and 
that if the life of the child is not destroved within the first week of the 



THE INFECTIOUS DISEASES. 265 

disease, a sure and steady improvement begins which leads to complete 
recovery. 

Diagnosis. — In diagnosticating this disease, the bacteriological aid is 
not so great in practice as it is in theory. The bacilli are difficult to discover, 
and frequently disappear early in the disease. Xot only are they very hard 
to find in smear, but their culture requires a blood serum which may be 
difficult to procure. Accordingly, in the great majority of cases, the phy- 
sician must depend entirely on clinical signs for a diagnosis. In some 
eases he has to rely largely on a process of exclusion. Wherever an illness 
quickly shows a prostration out of proportion to the apparent lesions, in- 
fluenza may be suspected. The tendency to spread through a family is 
suspicious, as the disease is highly contagious. This will be helpful in 
children, as adults usually contract the disease first, and the physician being 
informed of this will be helped in making his diagnosis. There are nearly 
always inflammatory symptoms in the nose and throat to help the diagnosis. 
The onset of acute tonsilitis or pneumonia will often cause confusion. The 
former usually has a higher temperature and a more abrupt onset, while the 
latter should show physical signs early in the attack. A central pneumonia, 
however, may require several days for a differentiation from influenza where 
both are suspected. In some cases, the course of the disease, with presence 
or absence of local lesions, will be all that will clear up the diagnosis. 

When influenza is epidemic probably other conditions are oftener ex- 
plained wrongly as due to this cause than vice versa. At any rate, a 
knowledge of its prevalence will put the physician constantly on guard in 
examining and diagnosticating obscure symptoms accompanied by pros- 
tration. 

Treatment. — The first requirement is isolation of the patient as far 
as possible, to prevent the disease spreading through the family. The 
room should be well ventilated with plenty of fresh air. as this not onlv 
supports the patient, but tends to prevent reinfection as well as the direct 
spread of the infection to others. Close, badly ventilated rooms often seem 
to hold the infection for a long time. The child should be kept quietly in 
bed. even in mild cases, and simple, easily-digested nourishment given. 
When the fever is high, reliance should be placed rather on frequent spong- 
Ings with cool or tepid water and alcohol than on the coal-tar derivatives. 
If there is much restlessness with the fever, small doses (one or two grains) 
of phenacetin with citrate of caffein may be given for a few doses at least. 
Where pain is evident, sulphate of codein. gr. 1/30 to gr. 1/20. for an infant 
of one year may be administered. For support and stimulation, sulphate 
of strychnin is most valuable, gr. 1/400 to gr. 1/300 every three or four 



266 DISEASES OF CHILDREN. 

hours for an infant of one year. From ten to twenty drops of whiskey or 
brandy may also be given when the pulse is weak. The bronchitis, pneu- 
monia, or gastroenteritis are to be treated as when occurring as primary 
conditions except that support and stimulation must be specially emphasized 
on account of the extra depression of the influenza. When the attack is 
prolonged or tending to constant recurrence, a removal to another section 
of the country may be the quickest way to recovery. 

Influenzal Meningitis. — In influenzal meningitis the fluid is quite 
uniformly cloudy, with a well-marked straw-colored sediment. In those 
instances in which a clear fluid has been reported the presumption must 
be that not enough fluid was abstracted to have drained the subdural spaces. 
The fluid abounds in polymorphonuclear leukocytes ' while the bacilli are 
found to be both intra- and extra-cellular, and do not differ morphologically 
from those obtained from other structures of the patient. 

Aside from making the diagnosis the practical feature is the treatment. 
Heretofore we have treated this type of meningitis as we would a pneumo- 
coccic, or in fact any meningeal inflammation with signs of infra-cranial 
pressure — namely by supportive measures and repeated lumbar punctures. 
The rapidity of the course in this type hardly allows us to await results 
with medication directed toward the invading organism, so that such a drug 
as hexamethylenamin (urotropin), for example, is of little avail. 

Wollstein in her valuable contribution to this subject has shown the 
curative possibilities of an immunized serum made from a virulent influenza 
organism. She calls attention to the need of making the diagnosis by punc- 
ture promptly, and the necessity of resorting to the serum treatment imme- 
diately after the diagnosis is confirmed. The mode of use is that 
recommended for Flexner's serum. 

Syphilis. 
Definition. — Syphilis is a communicable disease that may be acquired 
by inheritance or by direct contact after birth. In the latter case there is 
always an initial lesion, the chancre, followed by numerous secondary 
lesions, affecting principally the skin and mucous membranes, and by ter- 
tiary symptoms involving the bones, viscera, and the organs of the special 
senses. In hereditary syphilis there is an absence of the initial lesion and 
the disease shows itself in the secondary form from the beginning. 

Hereditary or Congenital Syphilis. 
Definition. — This is a form of the disease in which the infection is 
primarily derived from the father or mother. 



THE INFECTIOUS DISEASES. 267 

Method of Transmission. — Our knowledge of the transmission of 
this disease has recently been greatly increased by means of the Wassermann 
reaction. It seems probable that the mothers of all children having con- 
genital syphilis are themselves* syphilitic. Knoepfelmacher in a study of 
forty-five cases found that 56.2 per cent, gave a distinctly positive Wasser- 
mann reaction. More than half of these cases never gave any symptoms 
of, nor were ever treated for syphilis. The mothers of children having 
syphilis give as high a percentage of positive Wassermann reactions as do 
men who have reached the latent stage of syphilis. 

A positive Wassermann reaction in the mother lessens the possibility 
of the child being born sound. A mother may during a period of latency 
or of vigorous treatment give birth to a sound child, even though she at 
some later time again develops active symptoms. When the mother is 
suffering from acute syphilis it is transmitted in an active form to the 
child. The degree of such transmission depends upon the stage and severity 
of the disease and the nature of the treatment employed. 

The apparent immunity of the mother in fact does not exist, for if 
she bear a syphilitic child she herself is syphilitic. Coles' dictum, therefore, 
that " a new-born child affected with inherited syphilis, even though it may 
have symptoms in the mouth, never causes ulcerations of the breast which 
it suckles, if it be the mother who suckles it, although continuing capable of 
infecting a strange nurse " has been practically proven to be a fallacy. 
Profeta's law is likewise in error, for every child born of a syphilitic mother, 
no matter how healthy in appearance, is syphilitic if the mother shows any 
active symptoms of the disease. 

It is now almost a certainty that syphilis is never transmitted through 
the spermatozoa of the male. The disease is transmitted from father to 
child through the mother. A positive Wassermann reaction is obtained 
much less often in the father than in the mother, this probably being due 
to the fact that syphilis is in a majority of- cases a self-limiting disease, the 
dangers of transmission after the fourth or fifth year being greatly 
diminished. 

Pathology. — The spirocheta is widely distributed in the infant's body. 
According to Trinchese, they are found most abundantly in the suprarenals, 
then in the liver, lungs, ovaries, testes, spleen, the fetal end of the funis, 
and also with relative frequency in the blood. They are relatively rare in 
the placenta, but may be found in the stroma and on the surface of the 
villi. The migration of the spirocheta from the vessels of the villi to the 
surface of the villi and into the intervillious spaces is regarded by Trinchese 
as normal. 



268 DISEASES OF CHILDREN. 

The spiroeheta can, as a rule, be easily demonstrated in any of the superficial 
ulcerating areas by the " india-ink method " of Hech and Wilenko. A small drop 
of serum is pressed out of the tissues and placed upon a slide. To this is added 
a similar sized drop of india ink (Gunther's and Higgin's) and thoroughly mixed 
with a platinum loop. The mixture of serum and ink is allowed to dry, after 
being spread out as thinly as possible. This smear is then examined under an 
oil-immersion lens. 

The fetus may die at any time during the uterogestation with resulting 
miscarriages, or may live to term and then be still-born. When born alive, 
the lesions resulting from the disease may be broadly divided into those 
involving the skin and mucous membranes, the viscera, and the bones. 
There may be erythema, maculo-papules, or papules on the skin, or a 
vesicular and pustular eruption may occasionally be seen. Blebs or bullae 
often appear at birth in a severe type of the disease. Crops of boils, with 
well-defined, coppery-red bases, are apt to be symmetrically arranged when 
many are present, or asymmetrically distributed if only a few are seen. The 
lesions of the mucous membranes may take the form of inflammatory pro- 
cesses, of mucous patches, or of superfical or deep ulcerations. The junction 
of skin and mucous membrane is a favorite seat for the syphilitic lesion. 
The viscera are more apt to be involved in hereditary than in acquired 
syphilis, the lesion taking the form of an interstitial hyperplasia. The 
growth of interstitial connective tissue, which, by gradual contraction, 
partially obliterates the parenchyma of the organ, may involve the lungs, 
spleen, liver, pancreas, and testicle. Usually a portion of a lobe, but 
occasionally a whole lobe of the lung, may present a diffuse fibroid infiltra- 
tion with a grayish-white color. The liver, which is not infrequently 
affected, is hardened and enlarged from a diffused sclerosis, although oc- 
casionally the affection may be circumscribed. Gummata, in the form of 
small, circumscribed nodules, may be found in the lung, liver, or other 
viscera. Bone lesions are quite common and some that were formerly re- 
ferred to rickets or scrofula are now recognized as syphilitic. There are 
two principal ways in which the specific poison affects the bones in early 
life. In one instant the brunt of the disease and morbid change takes place 
at the junction of the shaft with the epiphysis — osteochondritis : in 
the other, the periosteum covering the long bones is principally 
affected with a resulting periostitis. Both of these varieties involve prin- 
cipally the long bones. Osteochrondritis develops early in life, usually 
within the first month. It may, however, occur later, when it is not apt to 
become multiple, and may be unsymmetrical in distribution. While epiphy- 
seal swellings may be due to rickets as well as syphilis, such swellings are 
pretty surely syphilitic if they occur during the first six months of life and 
they are relieved by mercurial treatment. Again, the epiphyseal swellings 



THE INFECTIOUS DISEASES. 269 

of rickets are always symmetrical, while those of syphilis may be unilateral. 
Periostitis occurs later in hereditary syphilis, usually after the child has 
begun to walk. It attacks by preference the femur, tibia, and bones of the 
forearm, occurring usually from the second to the fourth or fifth year. At 
an early stage of the disease the bones are attacked symmetrically, but later, 
circumscribed nodes may be placed unilaterally. 

A dactylitis attacking by preference the proximal phalanges of the 
metacarpal and metatarsal bones, enlarging them to several times their 
natural size, may occur. There is not much destruction of bone but after 
a time the skin mav become inflamed and break down from the formation 




Fig. 75. — Congenital syphilis. 

of an abscess. Craniotabes may result from the malnutrition of syphilis as 
well as from rickets. 

Symptomatology. — The symptoms vary greatly in severity from 
cases showing good nutrition and only one or two slight lesions, to such 
severe infection as to produce early death. In the latter case, the fetus 
may be attacked in the uterus resulting in abortion more or less early in 
pregnancy. As the disease lessens in severity in one or both parents the 
pregnancies will be longer in duration and finally an apparently healthy 
infant may be born. While there may be evidences of syphilis at birth, the 
onset is often delayed until weeks or months afterwards. In the majority 
of cases the primary symptoms will be noted before the end of the second 
month. The earlier the disease manifests itself after birth, the graver will 
be the nature of the attack. Very early syphilis is usually accompanied by 



270 



DISEASES OF CHILDREN. 



emaciation, severe coryza, cracked and ulcerated lips, eruptions of bullae, 
particularly upon the palms of the hands and soles of the feet, and evidences 
of visceral and bony disease. In the older cases there may be no apparent 
interference with nutrition, and possibly one or two mucous patches may 
be the only active manifestations of the disease. As noted in the pathology, 
almost any structure of the body may be involved in the course of the disease. 
The skin rashes often develop rapidly and are apt to be less symmetrical 
than those seen in adults ; they are likewise polymorphous, as several differ- 
ent forms .of eruption may be exhibited at the same time in a given case. 
There may be an eruption of small round pink spots, disappearing on pres- 






:U„ 



<V -' ■ < 









iJ >$/€- ■ y n -jv ■ v • 



y 



Fig. 76. 



Section of liver from syphilitic infant, showing large numbers 
of spirochete. 



sure, and usually appearing first on the lower portion of the abdomen. 
These may later take on a coppery discoloration. A papular syphilid may 
be seen in the form of small or large flat papules which are not so apt to 
group themselves into lines and circles as in older subjects. Neither are 
they so solid and deeply infiltrated as in the adult. Upon the palms and 
soles these papules may be very abundant and fuse together, presenting a 
thickened, dull-red surface. The vesicular syphilid is not common; the 
vesicles may be associated with pustules, and appear in closely-arranged 
groups about the mouth and chin or various other parts of the body, es- 



THE INFECTIOUS DISEASES. 271 

pecially the nates and hypogastrium. Pustules may appear on the face, 
buttocks and thighs. Pemphigus, so-called, is seen only in the severer forms 
of the disease and then preferably on the palms of the hands and soles of 
the feet. A smoky discoloration of the skin, seen most distinctly in the 
prominent parts of the face, such as the eyebrows, cheek-bones, and bridge 
of the nose, may occasionally be the only manifestation on the skin. There 
is apt to be a dryness of the skin whcih may hang in loose folds from the 
general cachexia. 

The mucous membranes are early affected. One of the most typical 
symptoms is the eoryza. At first there may be a serous discharge which 
gradually becomes worse until the nasal secretion takes on a purulent or 
even a bloody character with excoriations of the upper lip. The secretion 
may become inspissated, forming crusts, which may completely block up the 
nasal passage. There is often flattening of the bridge of the nose from 
interference with respiration. Mucous patches are oftenest seen in the 
mouth, about the nose, upon the scrotum, vulva, labial commissures, and 
occasionally at the umbilicus. Deep fissures sometimes form at the corners 
of the lips, even extending well out into the cheek. There may be enlarge- 
ment of the epitrochlear, cervical, cervicomaxillary, axillary, and inguinal 
lymph-glands but there is not a general adenopathy. Condylomata are some- 
times found about the anus. 

The long bones should be carefully examined for enlargement and 
thickening of the epiphyseal and distal ends. The epiphysis may even be 
separated from the shalt, when crepitation will be found upon careful 
handling. Dactylitis is usually confined to one pharynx which will be en- 
larged to double its normal size, but there is not apt to be much involvment 
of the soft parts; several phalanges are sometimes attacked. Onychia, often 
followed by ulceration around the nail, is occasionally seen. The first teeth 
are delayed, poorly developed, and will probably undergo early decay. 

A profound anemia is sometimes seen, characterized by a diminution 
and alteration of the red-blood corpuscles, the appearance of megalocytes 
and microcytes and of nucleated erythrocytes. There is leukocytosis which 
may become extreme. 

There may be sufficient disturbance of nutrition to induce an atrophy 
of all the structures of the body, the infant persenting a weazened appear- 
ance. This is oftenesl seen in bottle babies and some infants that are 
nourished on the breast may remain plump and well nourished throughout 
the course of the disease with only a few mucous patches to give evidence 
of a mild infection. 



272 



DISEASES OE CHILDREN. 



Diagnosis. — It is usually easy to diagnosticate the disease from some 
of the pathological or clinical manifestations just described. In cases of 
marasmus, if there has been no chronic indigestion, particularly if the infants 
have been fed on the breast, syphilis may be suspected. Chronic coryza is 
suspicious and mucous patches will made certain a diagnosis. The follow- 
ing points are characteristic of syphilitic lesions : They are general in their 
distribution, but ambulatory and changing, and usually present a reddish- 
brown tint; where crusts form they are fairly thick, with a tendency to 
accumulate in layers, and when cicatrices form they are smooth and long, 
surrounded by a pigmented areola. The bony lesions of syphilis, tubercu- 
losis and rickets may be confused. Morrow gives the following points of 
differentiation between syphilis and tuberculosis: 1. Syphilis exhibits a 
marked predilection for the long bones; its habitual localization is in the 
diaphysis, and almost always at its terminal extremity. Tuberculosis is 




Fig. 77 — Syphilitic dactylitis 



almost exclusively situated in the epiphyses, rarely affecting the shaft. 
2. In syphilis there is a marked enlargement of the bone by more or less 
voluminous tumors or hyperostoses, with little or no involvment of the 
soft parts; in tuberculosis the tumefaction is due less to increase in the 
size of the bone than to edematous infiltration of the soft structures. 3. In 
syphilis there is little tendency to suppuration and necrosis; in tubercu- 
losis the pyogenic tendency is marked. 4. In syphilis, osteocopic pains, with 
tendency to nocturnal exacerbation are a pronounced feature; in tuberculosis 
the pain is dull and heavy, not aggravated at night. 5. The osseous lesions 
of syphilis rarely react upon the general system, while those of tuberculosis 
often determine a marked impairment of the general health. 

In differentiation of syphilis from rickets, epiphyseal swellings under 
six months are very apt to be syphilitic. In syphilis the epiphyseal swelling 



THE INFECTIOUS DISEASES. 273 

may be unilateral, but it is always symmetrical in rickets. In doubtful 
cases the swelling must be subjected to specific treatment. It is well to 
remember, however, that rickets and syphilis may coexist in the same case. 

Prognosis. — The earlier the symptoms appear after birth, the severer 
will be the type and the worse the prognosis. Breast-fed infants have a 
much better chance than those artificially fed. If the digestion remains 
good and the manifestations of the disease are not severe, complete recovery 
takes place and the infant may grow up healthy and strong. The average 
prognosis, however, is bad. Kassowitz states that one-third of all syphilitic 
children die before birth, and among those who are born 34 per cent, die 
in the first six months of life. 

Treatment. — Parents who exhibit any specific symptoms or who have 
had syphilitic children should be subjected to specific treatment in the hope 
of avoiding infection of the fetus. Mercury is the specific remedy and may 
be administered to an infant either externally or internally. Daily inunc- 
tions of mercurial ointment, mixed with from two to eight times its quantity 
of vaseline or rose ointment, may be employed. A lump about the size of a 
small hickory nut may be rubbed on the inside of the thighs or in the 
axilla?, the parts having previously been cleansed with soap and warm water. 
It is more cleanly to apply five drops of a 10 per cent, solution of oleate of 
mercury three times daily. Internally, mercury with chalk is one of the 
best preparations in doses of one-fourth to one grain three times a day. 
Calomel, in doses of 1/20 to 1/6 grain, three times daily, will have a more 
rapid action when such is desired, or bichloricf of mercury 1/200 to 1/60 
grain may be given. If the latter induce intestinal irritation, a menstruum, 
containing bismuth, will usually allay it. When mercury is given for a 
long time it is well to occasionally change its form, although in syphilis 
it is a tonic, acting like iron in anemia. The nostrils must be kept clear, 
using, if necessary, some bland oil like albolin. Mucous patches and ex- 
coriations must be kept clean and dusted with calomel and bismuth, equal 
parts. It is usually necessary to give mercury for at least a year, with 
occasional intervals of tonic treatment. In visceral lesions and where the 
bones are involved and evidence of gumma in any part of the body appears, 
iodid of potassium, in doses of 1 to 5 grains, will be indicated. The general 
care and feeding is most important. While the infant should not, if possible, 
be taken from the mother's breast, it must never be given to a wet-nurse. 

Ehrlich's Preparation. — Recently there has been placed on the market 
a drug under the trade name of neosalvarsan. The drug is an arsenic 
preparation, and must be given in large doses in order that it may produce 
IS 



274 DISEASES OF CHILDREN. 

its effects quickly, as otherwise the spirocheta become " arsenic fast," i. e., 
are not affected by arsenic. 

Neosalvarsan is a much safer preparation for children than salvarsan. 
Following the injection there is a rapid improvement of all the symptoms. 
It is a mistake to suppose, however, that there is a complete cure from one 
or more injections of the drug. As a rule it is necessary to continue the 
use of mercury in some form not only before but after the treatment with 
neosalvarsan. When given intramuscularly there is some danger of the 
formation of a slough. Injection into the deep tissues is always accompanied 
by pain. The dose is about 0.04 per pound of body weight. 

As neosalvarsan is a neutral salt its preparation is a simple matter, the 
drug being mixed with cold distilled water. The injection into a child's 
vein is not a simple matter. Occasionally the vein can be directly entered 
through the skin, but not infrequently it is necessary to expose the vein. 
At the present time a 5 per cent, solution of the drug can be injected into 
the blood stream with no ill effects. 

These injections of neosalvarsan should not be given by the general 
practitioner, but should be left to those who have perfected their technic 
by special study. Whenever possible the case should be in a hospital where 
there are special facilities for sterilization and skilled assistance. It is a 
method of treatment which should be reserved for syphilitics who need rapid 
heroic treatment or for those cases not doing well on routine treatment. 

The course of the disease should be carefully followed by the Wasser- 
mann reaction, and occasional tests should be made after all symptoms have 
disappeared. 

Late Hereditary Syphilis. 

This form of syphilis comprises those cases in which early evidences 
of the disease have either not existed or have been in such slight form as to 
have been overlooked. Late hereditary syphilis may manifest itself either in 
certain active lesions plainly to be attributed to this condition or by certain 
developmental defects that may easily be confused with tuberculosis or 
rickets. 

The secondary teeth are affected in a way that has been considered 
pathognomonic. The principal change is noted in the two superior middle 
incisors, which are small, peg-shaped with scooped-out grinding edges, and 
placed at such an angle that the cutting borders, if continued, would meet. 
They may occasionally be deflected outward, and are known as Hutchin- 
son's teeth (Fig. 77). Ulceration of the palate, usually, beginning in the 
center, may take place and be followed by caries or necrosis of the bone. 
There may be simultaneous or consecutive deep ulceration of the soft palate, 



THE INFECTIOUS DISEASES. 



275 



pharynx, and nasopharynx at any time previous to the age of puberty. 
Large, indolent mucous patches may exist in the mouth, and there may 
be ulceration about the lips leaving long scars, especially at the commissures. 
The nasal bones may become necrotic with depression of the bridge from 
destruction of the bony arch. 

A periostitis, accompanied by a thickening on the surface of the bone, 
may involve the long bones, especially the tibia, ulna, radius, and humerus. 
The lesion may be multiple and symmetrical, although occasionally uni- 
lateral. Gummata, involving the bones and occasionally the soft tissues, 




Fig. 78. — Hutchinson's teeth. (Dr. FrauenthaVs case.) 

may be seen, and, in the latter case, may break down with ulceration and 
leave large scars. Interstitial keratitis, without much congestion of the con- 
junctiva, is not infrequent, and is liable to be followed by corneal opacities; 
although primarily attacking one eye, it may involve the other. There may 
coexist an indolent iritis without the usual severe pain and photophobia. 
A chronic form of otitis may be followed by deafness. Painless enlargement 
of one or both testicles may be caused by syphilis, but there will be apt to 
be lesions in other parts of the body to aid in the diagnosis when this occurs. 
In many cases all the evidence of syphilitic taint in childhood will be found 



276 DISEASES OF CHILDREN. 

in arrested and perverted development. As an example, the testicles at 
puberty may be about the same size seen in very early childhood, and in girls 
in absence of mammary development, delayed menstruation and a non- 
appearance of hair on the genital and axillary region may be noted. 

Yeeder and Jeans in their recent report state that the incidence of 
manifest hereditary lues of the late type is much greater in proportion to the 
incidence of early syphilis than previous figures would indicate. Lesions 
of the central nervous system appeared in 43 per cent, of their cases. 
Acutely developing lesions responded promptly to intravenous injections of 
neosalvarsan, but permanent results are to be obtained only by prolonged, 
intensive mercurial treatment. 

The Wasserman reaction, even if once negative, returned if the treat- 
ment was discontinued, and a negative reaction could not be obtained in 
some cases even after two years' active treatment. In other words it is felt 
that late hereditary lues cannot be eradicated. 

Treatment. — The treatment of the later forms of syphilis must depend 
on the activity of the morbid process. Mercury in some form should be 
exhibited when there is evidence of active syphilitic disease. Iodic! of 
potash is also to be given in fair doses, three to five grains. The treatment 
should also be directed toward improving the nutrition of the child in everv 
way. Good food, iron, cod-liver oil, are all of value in aiding healthy growth 
and development in these retarded cases. ( See treatment with neosalvarsan, 
page 273.) . 

Acquired Syphilis. 

The syphilis detected in early life, although usually hereditary, is not 
necessarily so, but may be acquired. A primary sore upon the genital tract 
of the mother can possibly infect the infant during birth. The nurse or 
attendant may have a primary lesion upon the breast or lips. Much more 
common will be infection from some secondary lesion, especially a mucous 
patch upon the mouth or lips. There are many ways in which the blood 
or infective secretions of a syphilitic patient may come in contact with a 
solution of continuity in the skin or mucous membranes of an infant or 
child. A chancre will then appear at the point of contact, followed in due 
time by the later manifestations of the disease. Rarely, in older children, 
the disease may be contracted by sexual contact. The symptoms and treat- 
ment present essentially the same elements as in adult life, and hence will 
not be considered here. The acquired disease in the infant or young child 
tends to be milder than the hereditary form in its symptoms and less apt to 
affect seriously the general health and development. 



THE INFECTIOUS DISEASES. 277 

Epidemic Cerebrospinal Meningitis. 

(Cerebrospinal Fever.) (Spotted Fever: Obsolete.) 

This form of meningitis is an acnte infectious disease due to the dip- 
lococcus intracellularis, characterized by motor and sensory cerebral and 
spinal svmptoms. 

Etiology. — The disease, without question, has its specific germ in the 
diplococcus intracellularis meningitidis, fully described by "Weichselbaum in 
1887. 

This organism, fortunately of low resistance, gains access to the general 
system through the blood or through some local determination in the naso- 
pharynx, ear, or eye, and in those with depleted vitality and lowered resist- 
ing force finds suitable soil for its propagation. It usually occurs in epidemic 
form, although occasional sporadic cases are seen from time to time, 
especially in the large centers. 

The spring of the year, after prolonged confinement to ill-ventilated 
and superheated apartments, finds the greatest number of predisposed indi- 
viduals. It is essentially a disease of the young. Our youngest case was 
twelve weeks old, although Botch, of Boston, reports a case six days old. 
The second year claims the greatest number of victims. 

Pathology. — In making postmortem examinations of those dying with 
the disease, we find, as a rule, an exudative inflammation of the pia arachnoid 
of the brain and spinal cord. The amount of infiltration found, however, 
often does not correspond to the gravity of the symptoms observed during 
the life of the patient. The degree of infiltration varies from an intense 
hyperemia to a fibrinoplastic seropurulent or purulent exudate. This exu- 
date is most marked at the base of the brain and along the fissure of 
Rolando and the dorsal portion of the cord. In the ventricles is found a 
cloudy or opaque serum and in a few cases pure pus. The effusion in the 
subarachnoid space (and it must always be kept in mind that there is more 
fluid in the subarachnoid space in children than in adults) is increased in 
normal amount. Frequently there is seen a parenchymatous degeneration of 
the kidneys, degeneration of the heart muscle and the muscles in general. 
There will also be found in a number of cases multiple abscesses, septic 
joints and ecchymoses of the skin as a result of complicating conditions. 

Symptomatology. — In cerebrospinal meningitis the symptoms vary 
according to the type of the disease present. The onset is usually sudden 
and abrupt. The malignant types are seen largely in the epidemics only, 
and are responsible for the large mortality record. In this type headache, 
vertigo, vomiting, and high fever are soon followed by coma and death. 

The symptoms in the sporadic cases will vary with the gravity of the 



<o ib DISEASES OF CHILDREN. 

local lesion and the intensity of the toxemia. The history of the prodromal 
period may be of material assistance in establishing the diagnosis ; there is 
malaise, headache, chills, loss of appetite, body pains, and some rise of 
temperature. Later frontal headache is complained of and succeeded by 
vomiting, restlessness, and rapid pulse. Herpes on the lips and nose, 
retraction of the posterior cervical group of muscles, hyperesthesia and 
opisthotonos are observed. The general nutrition suffers severely and ema- 
ciation is steady and progressive. Delirium, stupor, or profound coma 
develop. Convulsions of a severe type (particularly in infants and younger 
children) are apt to occur at or near the beginning of the disease. The loss 
of flesh and strength is rapid and marked. Photophobia and irregularity 
of the pupils with loss of pupillary light reflex and nystagmus are quite 
regularly present. Neuroretinitis is found on ophthalmoscopic examination 
of the fundus in some cases. The respirations vary with the stage of the 
disease; they are increased when the fever is high, sighing and shallow 




Fig. 79. — Cerebrospinal meningitis with marked opisthotonos. 

when stupor begins and are irregular when coma develops. The blood 
shows a leukocytosis rarely under 25,000 to the cubic millimeter. The tem- 
perature curve is not characteristic and bears no relation to the prognosis. 
The excursions are wide and varied. The pulse is rapid and sometimes 
irregular. Ecchymotic spots and purpuric areas are seen in some of the 
fulminating cases, but a roseola or an erythema is more apt to occur in the 
sporadic cases. 

The reflexes will help to establish the diagnosis, but must be interpreted 
with caution. The tache cerebrale is always obtained, but is only a minor 
confirmatory sign. The Babinski reflex, or extension of the great toe on 
irritating the plantar surface of the foot, is confirmatory, especially in chil- 
dren over two years of age, although negatively it may be of assistance. 
Kernig's sign, which is obtained in nearly all the cases at some stage or 



THE INFECTIOUS DISEASES. 279 

other, is also present in all forms of cerebral irritation. Brudzinski's sign 
is a rather recent but valuable sign in meningitis. It is elicited by placing 
the left hand on the thorax and forcibly and rather suddenly depressing 
the chin to the sternum. If the extremities have been previously relaxed, 
they will now be quickly flexed until a crouching attitude is assumed. 

Macewen's sign, or the hollow note elicited by percussion over the 
parietal bone, is obtained only in those cases in which fluid has accumu- 
lated in excessive quantity in the ventricles. The rigidity of the neck, with 
dilatation of the pupils when attempts are made to flex the neck, is also a 
helpful and confirmatory sign of meningitis. 

The urine in the course of the disease often contains albumin and hyalin 
casts, the result of toxic substances in the blood stream. Loefler and Gour- 
and, of France, have called attention to the fact that in the beginning of 
the disease large amounts of urine of low specific gravity are passed, con- 
taining a high percentage of urea. An examination of the blood will assist 
in making a differential diagnosis. Leukocytosis, principally of the poly- 
morphonuclear cells, is present, while the mononuclear elements predomi- 
nate in the tuberculous type of meningitis. Lyons classifies the order of 
importance of the clinical signs. First in importance he noted the value 
of lumbar puncture in 95 per cent.; second, rigidity of the neck in 95 per 
cent of the cases; third, Kernig's sign in 90 per cent, of cases; fourth, 
Brudzinshi's sign early in 75 per cent., later in 94 per cent, of cases ; fifth, 
contralateral sign early in 33 per cent., later in 50 per cent, of cases; sixth, 
Babinski's sign in 11 per cent. He places no value upon patellar reflexes 
as a diagnostic aid in his cases. 

Lumbar Puncture. — Although the diagnosis can often be made from 
the clinical phenomena alone, confirmation and temporary relief from intra- 
cranial pressure symptoms are afforded by lumbar puncture, and it is also 
an aid in establishing the diagnosis and prognosis. The procedure is not 
difficult, and if performed with aseptic precautions and a due regard for 
the anatomy, is productive of no harm. The technic is as follows (also 
see Fig. 19, page 51) : 

Infants in whom opisthotonos has not yet developed may be placed 
over a pillow at the end of a table, the spine and outlying soft parts being 
thus put on the stretch. The spine may be entered between the third and 
fourth lumbar vertebrae. This space is found by an imaginary line drawn 
across the iliac crests and intersecting the spine. In older patients, or those 
with opisthotonos, it is necessary to place them on their side and enter to 
one side of the median line. The needle of an ordinary good-sized aspirat- 
ing syringe cannot be improved upon for the procedure. A small trochar 



280 DISEASES OF CHILDREN". 

and cannula may also be used and 10 to 15 c.c. (J ounce) should be with- 
drawn, provided the fluid flows freely, as this amount will include fluid 
from the cranial cavity and lead to more accurate bacteriological results. 
It is not wise to withdraw more than 30 c.c. or an ounce at a sitting. In 
infants with an open bulging fontanel, an amount can be withdrawn which 
will appreciably depress the fontanel. Dry taps, which occasionally occur, 
are usually the result of imperfect technic, the operator either not reaching 
the spinal canal, or the needle becomes obstructed with blood. If the 
exudative processes have occluded the connection between the ventricles of 
the brain and the cerebral and spinal subarachnoid spaces, as sometimes 
occurs in well-advanced cases, the opening may be partially occluded and 
the fluid flow very sparingly. In cerebrospinal meningitis the fluid obtained 
is generally clouded or turbid, sometimes it is purulent or, again varies from 
time to time. In a small percentage of cases it is quite clear throughout. 
It contains the diplococcus intracellulars, and in some aspirated fluids in 
addition, staphylococci and streptococci are found. Polynuclear leukocytes 
predominate and contain the specific organisms. 

Complications. — Those which may be attributed more directly to the 
disease itself are those of the eye, the ear, the brain, and the joints. The 
drum frequently is infected and may result in deafness and the labyrinth 
is apt to be likewise involved. 

Chronic hydrocephalus develops in a number of cases beginning either 
during the acute stage or in convalescence. These children are usually 
mentally deficient or idiotic. Barely an arthritis develops in one or more 
joints. 

Differential Diagnosis. — As a rule, the symptoms are typical enough 
to make the diagnosis of meningitis, which is confirmed and further differ- 
entiated by lumbar puncture. The sudden onset, the headache, fever, vom- 
iting, or convulsions in the face of an epidemic are especially significant. 
Meningitic symptoms in typhoid fever with rapid onset are often confusing. 
The blood examination for leukocytosis and the Widal reaction should be 
used to assist in the differentiation. Tuberculous meningitis, especially in 
infancy, is often confused with sporadic cases of cerebrospinal meningitis, 
and indeed the pathological examination of the spinal fluid may in some 
cases be absolutely necessary to differentiate them. The slow onset in 
tuberculous meningitis, the low leukocyte count, and the absence of hyper- 
esthesia are distinctly helpful points. 

Prognosis. — : We can base our prognosis on the following facts : Spo- 
radic cases have a greater natural tendency to recovery. Initial symptoms 
do not, as a rule, indicate the subsequent course. Mixed infections as found 



THE INFECTIOUS DISEASES. 281 

in the spinal fluid indicate a general septic condition and an unfavorable 
prognosis. The younger the patient the more unfavorable the outcome. 
Do not interpret as a sign of restoration to health a temporary remission 
with return of consciousness from coma. 

Widely dilated, rigid pupils, unvarying coma with slow pulse, sub- 
normal temperature, persistent opisthotonos, and convulsions are signs 
tending to a fatal termination. 

Treatment.-^ The germ and its toxins must be combated. Detailed 
study of the portals of entry of the infecting organisms has thus far failed 
to establish much that is new. Care of the nasopharynx as insisted upon 
by Jacobi and Caille is a local measure productive of much good, especially 
in the crowded centers. School inspection and a higher standard of sani- 
tary regulations in every district will do much to prevent epidemics of this 
disease. 

Serum Treatment. — The promising results that have been obtained 
from the use of Flexner's antimeningitis serum when used by the subdural 
method warrant its use in cases in which the diplococcus intracellularis has 
been demonstrated. It is ineffective in other conditions. If the bacterio- 
logical test is impracticable or would be unduly delayed, the serum injection 
is advisable in those cases in which a cloudy fluid is withdrawn by lumbar 
puncture. Xo harm is done if the disease is of another type. The earlier 
the serum is injected the better the results. By its use this long exhausting 
disease appears to be shortened and serious complications prevented. The 
serum is injected through the same needle after the withdrawal of at least 
30 c.c. of spinal fluid, or until the drops flow only 4 to 5 to the minute. 
The serum is warmed to body heat and slowly injected into the canal unless 
undue resistance contraindicates. Although a syringe may be used, it is 
best to allow the serum to flow in by gravity, using a funnel (or even the 
barrel of the syringe) attached to a piece of one-quarter-inch rubber tubing 
about a foot and a half long. An infant should receive 10—15 c.c. of the 
serum, while a child may take 20 c.c. It is wiser never to inject more than 
the fluid withdrawn, preferably 5 c.c. less. 

Cases with severe symptoms should be reinjected every twelve hours 
until there is improvement. Milder cases, once a day will answer. When 
the symptoms abate or the fluid on examination gives no culture, the 
injections are stopped. 

General Treatment. — A very important element of the treatment is 
conservation of the patient's strength by well-regulated nourishment and 
skillful nursing. Care of the excretory functions and relief of pressure 
symptoms are important elements of the treatment. The patient should be 



282 DISEASES OF CHILDREN. 

isolated in a well-ventilated quiet room, the eyes shielded from the light, 
the head and the neck being raised upon a pillow to relieve in part the 
congestion of the brain. The bowels are kept open by calomel or enemas. 
The diet may be fluid or semifluid, of a stated quantity, and careful note 
kept of the amount ingested. Forced feeding should be resorted to if neces- 
sary by gavage. Water should be given freely. An ice-bag should be 
applied intermittently to the head if the temperature rises above 101° to 
102° F. Warm baths at 115° F. for twenty minutes, twice a day, with 
cold applications to the head, do much to produce comfort and allay pain. 
While in the bath the nasopharyngeal toilet can be made with normal saline 
solution. Colonic irrigations are used to eliminate the toxins, promote the 
flow of urine, and to stimulate the patient. When they are given at a 
temperature of 80° F. they also control the higher rises of temperature. 

The baths will also prevent in great measure the formation of bed-sores, 
and the necessary change of position will be beneficial to the pulmonary 
circulation. 

For the relief of marked restlessness or convulsions bromids and chloral 
per rectum are to be preferred to the opiates. Camphor in sterile olive oil 
hypodermatically (one grain to ten minims) is given when stimulation is 
necessary. 

Lumbar Puncture : This procedure will be indicated for (a) purposes 
of diagnosis ; (b) in infants where there is a bulging fontanel or in children 
where Macewen's sign can be elicited, and in any case to control convulsions 
or sudden onset of coma; in other words, symptoms of intracranial pressure, 
and (c) for the injection of the antimeningitic serum. 

Poliomyelitis. 

{Infantile Paralysis. Essential Paralysis of Children. 
Acute Atrophic or Wasting Paralysis.) 

Definition. — An acute inflammatory process taking place in the an- 
terior horns of the spinal cord, accompanied by a sudden and complete 
paralysis of various groups of voluntary muscles, followed by a rapid wasting 
of the affected muscles. 

Etiology. — The specific causative agent is a non-filterable organism, 
ultra-microscopic, about one-quarter the size of the streptococcus, and has 
been recovered by Flexner through the nasal mucous membrane. It is first 
located in the olfactory lobe, then in the medulla and later 'in the central 
nervous system. It is taken up by the lymphatics. Thus far it has not 
been found in the blood current. Flexner is a firm believer in carriers as a 
means of spreading the disease and originating new epidemics. The organ- 
ism may remain alive in the body for a vear and a half. 



THE INFECTIOUS DISEASES. 283 

Special liability to the disease exists below the age of three years, fully 
lialf of the eases occurring during this period. The common house fly is 
regarded as a carrier of the disease. Cases occur oftenest in warm weather 
and boys are attacked oftener than girls. Occasionally the disease comes 
on after exposure to cold; it may also be seen in connection with certain 
infectious fevers, such as scarlatina and typhoid fever. The relation be- 
tween these factors and the disease, as to cause and effect, is somewhat 
uncertain. 

Pathology. — The inflammation that is localized in the anterior horns 
of the spinal cord seems to be induced by some toxin brought there by the 
blood current. There is dilatation and proliferation of the endothelial 
walls of the blood-vessels of the part of the cord affected. The central 
arteries of the spinal cord are intensely congested, followed by those of the 
anterior median fissure. As the posterior horns are chiefly supplied with 
blood from the peripheral arteries, they are less affected when the inflam- 
mation is limited to the distribution of the central arteries. After engorge- 
ment of all the arterial twigs, diapedesis opcurs and infiltration of the 
tissue by small cells and serum. According to Goldschreider, it is this 
choking of the gray matter by the inflammatory products that leads to the 
suspension of functional activity, and when, as in many cases, from impov- 
erished nutrition the cells of the anterior horns are actually disintegrated 
by the inflammatory products, permanent destruction of the nerve tissue 
ensues. The ganglion cells soon show granular degeneration, which may 
be followed by disintegration and atrophy. The cells in the anterior horns 
are arranged in groups having definite physiological motor and trophic 
functions. "When these cell groups are finally destroyed and replaced by 
connective tissue, the parts they innervate will likewise undergo degenera- 
tive changes. The muscles become atrophied, and their fibrils replaced by 
connective or adipose tissue. 

Symptomatology. — The invasion is usually acute with evidences of 
general infection. There may be gastroenteric or nervous disturbances with 
fever. The disease often begins with vomiting, and diarrhea may occa- 
sionally ensue. In other cases, general convulsions are seen at the begin- 
ning. Very rarely stupor or coma may follow the convulsions and last for 
a day or so. The temperature is frequently high at first, perhaps reaching 
104° or 105° F. : in other cases it is slight — not more than 100° or 101° 
F. In rare instances the initial symptoms may be so mild as to escape 
attention and the paralysis is the first thing noted. In the majority of 
cases, however, some initial symptoms, more or less marked, will last from 
one to four days before paralysis is discovered. Not infrequently pains in 



284 



DISEASES OF CHILDREN. 



the limbs may precede and accompany the paralysis for a time, and thus 
simulate peripheral neuritis, but such pains do not last long. The most 
obscure cases are those in which the child is suddenly found to be unable 
to stand or walk, perhaps after being taken out of bed in the morning. 
The paralysis is absolute, the affected part being completely flaccid. It 
develops rapidly, usually reaching its full extent in from twenty-four 
to forty-eight hours; in rare cases it may be slower in onset, so that a 

week or even longer may elapse before 
it appears to reach its maximum extent. 
There is then a more or less rapid sub- 
sidence of the loss of power, but little 
change is to be noted during the first 
three or four weeks after the beginning 
of the attack. Most of the improve- 
ment will take place during' the first 
j Jj three months, and after this interval 

any paralysis remaining will usually be 
permanent. The paralysis most often 
takes the form of monoplegia, the right 
leg being oftenest affected. The left 
leg and the right or left arm may be- 
come involved with a frequency usually 
in the order named. In severe cases 
all four extremities may be involved 
and even the muscles of the back and 
neck so that the child cannot sit erect 
or hold its head up. In very rare in- 
stances the medulla and base of the 
brain may be attacked, as well as the 
anterior horns of the cord, forming the disease called by Strumpell polio- 
encephalitis. The cranial nerves may then become affected and the patient 
shows signs of bulbar paralysis a$ well. These severer types are more apt 
to be seen when the disease is epidemic. In other rare instances there may 
be hemiplegia simulating cerebral paralysis. Paraplegia is rare. Many 
cases will only show a paralysis involving one group of muscles, as the 
peroneal type. As the motor cells in the anterior horns are arranged in 
groups, the muscles involved will be found to have a coordinated physiolog- 
ical function. The limb affected is apt to be cooler than the other parts, 
and an atrophy soon affects the paralyzed muscles. The wasting may be 
noticed within a week or two, and at two or three months becomes very 




Fig. 



80. — Foot drop in anterior 
poliomyelitis. 



THE INFECTIOUS DISEASES. 



285 



marked. Eventually various deformities result as the growth of bone is 
arrested and the whole limb becomes smaller. Where only one or two 
groups of muscles are affected by atrophy, the opposing healthy muscles will 
produce other deformities. In old cases, where a whole limb has been 
affected, there will be various grades of subluxation from a relaxation of 
the muscles and ligaments around the joints. The knee and shoulder are 
particularly apt to be involved in this way. The electrical reaction of 
muscles and nerves may prove helpful in recognizing the disease. AVhile 
the galvanic and faradic responses may be increased in the first two days, 
there is soon a loss of response to the faradic current with a reaction of 
degeneration to the galvanic current shown by the anodal closure contraction 
being greater than the cathodal closure contraction. If the part affected 
responds to faradism within a few weeks it will probably not be permanently 
paralyzed. 

The reflexes are lost in the affected muscles. The commonest example 
of this is seen in loss of the knee-jerk. Complete recovery of all the muscles 
affected is extremely rare, although the permanent paralysis may be limited 
to only one or two groups of muscles. Death may take place during the 
early course of the disease in the encephalic form during epidemics. 

Diagnosis. — It is impossible to make a positive diagnosis before the 
onset of the paralysis, as the first symptoms resemble those of other acute 
infections. However, an absolute paralysis preceded by vomiting, fever or 
convulsions points to a spinal origin. In a few cases there may be early 
cerebral symptoms simulating cerebrospinal meningitis, but paralysis comes 
later, if at all, in the latter disease, and the stiff retracted head comes early. 
On lumbar puncture the fluid is usually found to be under pressure, but 
clear or opalescent. The cytological characters of a cerebrospinal meningitis 
are absent. It is not always easy to differentiate a palsy as cerebral, spinal 
or peripheral. The following points may be considered as helpful : 



Cerebral 
(or motor projection fibers 
spinal tracts.) 



Ons.-t sudden, with convulsions. 



Usually affects entire limb and in- 
complete. Paresis. 



Hemiplegia (rule) 
Monoplegia (rare) arm 
Paraplesria (very rare) 



Spinal 
(gray matter i 



Onset sudden, with fever 



Affect muscular srroups 
h a v i n g coordinated 
functions and not sup- 
plied by simply one 
nerve. Total paraly- 
sis (rule). 



Monoplegia (rule) 
Hemiplegia (rare) 
Paraplegia (rare) 



leg 



Peripheral 
(nerves) 



Onset gradual (1 to 4 
weeks). 

Affects muscles supplied by 
one nerve. Total paraly- 
sis (rule i. 



Paralysis symmetrical. 
Paraplegia the rule. 
Upper, lower or all four 
extremities. 



286 



DISEASES OF CHILDREN". 



Cerebral 

(or motor projection fibers in 

spinal tracts) 

Muscles stiff or rigid 

Sensory disturbance usually ab- 
sent. If present, partial anes- 
thesia 

No atrophy, or late from disuse.. 
Deformity early. Athetosis 

Growth of part not much impaired 
Temperature of part little affected 

Increase of all reflexes 

No reaction of degeneration . . . 



Spinal 
(gray matter) 



Peripheral 
(nerves) 



Muscles flaccid 



Sensation not affected ; 
sometimes, but rarely 
general pains very early 
in disease. 



Early and rapid atrophy, 
Deformity late , 



Muscles flaccid. 

Association of sensory 
with motor paralvsis. 
Numbness, tingling, sen- 
sations of heat or cold. 
Limb usually painful 
along course of nerves 
affected. 



Atrophy rapid. 

Permanent 
rare. 



contractures 



Growth much impaired. . . 

Some coolness in affected 
limb. 



Loss of reflexes. 



Mind often affected, 
epilepsy. 



Weakness or 



Always reaction of degen- 
eration. 

Mind clear and no mental 
sequela?. 



Growth not impaired. 

Slight coolness of muscles 
affected. 

Loss of reflexes. 

Usually reaction of degen- 
eration. 

Mind clear and no mental 
sequelae. 



Prognosis. — A more or less rapid lessening in the extent of the paral- 
ysis nearly always occurs during the first few weeks after the beginning of 
the attack. There will be little or no improvement after the third or fourth 
month. The prognosis for muscles that waste rapidly is poor. A reaction 
to the faradic current is a sign of beginning improvement. After a year 
the condition will be absolutely stationary as far as the paralysis and trophic 
disturbances are concerned. Complete recovery is exceedingly rare, and is 
more apt to be seen in the epidemic form. In some cases, however, so few 
muscles are permanently paralyzed as to simulate entire recovery. The 
prognosis for life is exceedingly good, although a few will occasionally die 
early in the attack in epidemics of the disease with symptoms of severe 
infection. As there is no involvement of the brain, the mind will not be 
in any way affected, and there are no late sequelae such as epilepsy. 

Treatment. — Recent research work would indicate that mild antiseptic 
lotions applied to the nasopharnyx, may be valuable for proprMaxis. 
Urotrophin in fairly large doses may be administered as a preventative 
during epidemics as well as during the course of the disease. If seen 
early, and the temperature is high, ice-bags may be applied to the spine. 
When this is discontinued, stimulating applications may be applied, 
such as one part of turpentine in two parts of camphorated oil, sprinkled 
over a strip of flannel. Long strips of mustard paste may be applied 
to the spine. The bowels should be kept open and a mild, unstimulat- 



THE INFECTIOUS DISEASES. 287 

ing diet given. Any irritability of the nervous system may be con- 
trolled by bromid of sodium — from three to five grains, every three or 
four hours. Absolute rest, in an easy, recumbent position, is very important 
during the first few weeks. No effort must then be made to stimulate the 
paralyzed muscles, and the parts must, if necessary, be kept in a natural 
position by straps or orthopedic apparatus to prevent early deformity by 
contractures. It is especially necessary in the case of drop-feet to raise and 
support these parts, 'after the symptoms of central nerve irritation have 
passed — usually in about three weeks. Strychnin and electricity may now 
be employed. If the muscles do not respond to the faraclic current, galvan- 
ism may be used. When the pain ceases and the patient can be handled 
without discomfort, massage, at first light and later deeper, should be given 
the affected parts. 

Ee-education, passive movements by the use of pulleys, and bran baths 
are all needed in the attempt to restore function. Persistent efforts, even 
when the returns seem meager, should be made.. The late deformities of 
the disease come before the orthopedic surgeon for correction. Tenotomy, 
various braces, and induced anchylosis for the " flail- joints " may all be 
required. 

The Epidemic Form. 

The occurrence of epidemics of paralysis in children has been reported 
in recent years by a number of observers. They have generally been con- 
sidered as cases of poliomyelitis, and have naturally provoked renewed dis- 
cussion as to the essential cause of this disease. The abrupt onset, the fever, 
the gastric disturbance, occasional attacks of convulsions seen both in the 
epidemic and endemic forms of the disease point to its infectious nature. 
In the epidemic form, a considerable variation from the usual type of the 
disease has been noticed, some cases presenting the symptom-complex of 
Landry's paralysis. Medin reported an epidemic during the summer of 
1887 in Stockholm, with some fatal cases. In this country Caverly re- 
ported an epidemic occurring in the summer of 1894 in Rutland, Vermont. 
One hundred and thirty-two cases were reported, occurring oftenest in 
strong, healthy children. Many of the cases showed marked hyperesthesia 
of the skin and others exhibited muscular rigidity of the neck or back. A 
curious feature of this epidemic was that domestic animals were affected by 
the disease. Horses, dogs, and fowls became paralyzed, and an autopsy 
on a horse and fowl showed the lesions of poliomyelitis. This epidemic 
occurred in a very dry season, and the same thing has been noted in most 
other epidemics. 

An interesting epidemic, reported by Chapin, occurred during the 



288 DISEASES OF CHILDREN. 

summer of 1889, at Poughkeepsie, N. Y., most of the cases being attacked 
between the middle of July and the middle of August. A peculiarity of 
this epidemic appeared to be the existence of severe pain in the parts affected 
by the paralysis. A number of the cases carefully examined showed abso- 
lute paralysis of the limbs affected, with loss of reflexes and apparently 
considerable pain on handling the part. 

During the summer of 1907 an epidemic of considerable proportion 
existed in New York and the surrounding country. In this epidemic pain 
in the extremities formed a marked feature, and in some cases marked 
cerebral symptoms were noted. Many of the cases showed great gastroenteric 
irritation at the onset of the disease. Occasionally headache and rigidity 
of the neck simulated cerebrospinal meningitis. A few cases were reported 
in which symptoms of bulbar involvement occurred. A number of deaths 
were also reported during this epidemic, the fatalities occurring early in the 
disease. The following points will fairly represent the peculiarities of the 
epidemic form of paralysis in children : 

1. The disease is occasionally fatal, especially early in the attack. 
The endemic form is rarely, if ever, fatal in its ending. 

2. There are great variations in the extent of the paralysis in the 
epidemic form. Many cases show very extensive palsy, involving all the 
extremities and the muscles of the back and neck as well. Other cases show 
a very slight loss of power, and the disease is doubtless occasionally over- 
looked from this cause. 

3. Pain seems to occupy a more prominent feature in the epidemic than 
in the endemic form. This pain may even last well along in the course of 
the disease. In the ordinary endemic disease, if pain exists it is not apt to 
last more than a day or so. 

4. A certain proportion of cases in these epidemics seem to undergo a 
complete recovery. This rarely, if ever, happens in the endemic form. 

5. The lesion tends to be more varied and extensive in the epidemic 
than in the endemic form. It may include the following conditions: 
Polioencephalitis of Strumpell; poliomyelitis; peripheral neuritis, and 
occasionally meningitis. 

Rheumatic Fever. 

(Acute Articular Rheumatism.) 

Rheumatic fever is a febrile disease of the joints characterized by transi- 
tory inflammatory attacks which do not tend to suppuration. 

Etiology. — The infectious origin of the disease is accepted as a fact ; 
although the direct etiological factor is still in dispute. The disease as- 



THE INFECTIOUS DISEASES. 289 

sumes certain characteristics in childhood which distinguish it from the 
adult type. The course is milder and shorter, while involvement of the 
heart is more frequent than in adults. 

Single epidemics and a succession of epidemics have heen reported from 
time to time. Several members of the same family may be attacked simul- 
taneously. 

The oral cavity and more particularly the tonsils have been regarded 
by many as the portal of entry of the infecting organism. Predisposing 
factors are exposure and residence in cold damp apartments. Heredity 
seems to play a distinct part if the predisposing factors are present. 

The disease is not very common before the fifth year, although cases 
have been recorded during the nursing period. One attack predisposes to 
subsequent attacks. 

Among the 76 cases studied clinically by Chapin the following were 
the ages : 

• i mos.. 1 11 mos., 1 20 mos.. 1 3 .vrs. 1 4 vrs.. 2 5 vrs.. 4 

6 yrs.. 6 7 yrs.. 3 8 vrs.. 11 vrs.. 9 10 Vrs.. 5 11 yrs., S 

12 yrs.. 7 13 yrs., 9 14 yrs.. 4 15 yrs.. 2 17 yrs.. 2 

Symptomatology. — An attack may be preceded by languor, loss of 
appetite, mild tonsillitis, abdominal pains, and indefinite pains in the joints. 
With the localized pain there is a febrile reaction of variable intensity, 
102-104° F., and occasionally there is vomiting. The knee- and ankle- 
joints are, as in adults, most frequently involved. In children the hip and 
cervical vertebra? and joints of the fingers and toes may be the areas attacked. 
Usually more than one joint is affected, but symmetrical involvement is not 
the rule. It is exceptional for the attack to persist more than a few days 
in any one joint. The joints, as a rule, are not exquisitely painful on 
active or passive motion, while the swelling, if any, is moderate. The fascia 
covering muscles may be attacked without any involvement of the joints. 
The sternocleidomastoid muscle is especially liable to such attack. The acid 
perspiration so commonly observed in adults is rarely present in children. 
A waxy appearance is observed in severe cases with insomnia, anorexia, and 
insatiable thirst. 

The blood findings are of no assistance in making the diagnosis. Mild, 
almost afebrile cases may, however, be followed by serious involvement of 
the heart. 

Complications. — These bear a direct relation to the toxins of the 
disease itself. Rheumatism in childhood is characterized by its cardiac 
complications: it thus must always be considered as a disease of serious 
import. Nearly half of all the cases leave permanent cardiac effects. 

The mitral valve is most frequently affected. The involvement is 



290 « DISEASES OF CHILDREN. 

accompanied by irregular rises of temperature and increased pulse rate. 
The symptoms accompanying valvular defects, however, may be the first 
indication for medical attention and lead to the discovery of their rheumatic 
origin. Pericarditis is present in 10 to 20 per cent, of all cases in children 
and is frequently associated with endocarditis, and is an important and often 
fatal complication. Serous, or serofibrous pleurisy, is a complication seen 
in severe and long-standing cases. Pneumonia and occasionally nephritis 
are rarer complications, in all probability due to mixed infection. A pur- 
puric rash or an erythema may be seen as rheumatic manifestations. Chorea 
must be regarded as a distinct rheumatic manifestation and often may pre- 
cede the disease. Involvement of the endocardium is not rare in cases of 
chorea. Rheumatic iritis is rare in childhood, but can be diagnosticated by 
a competent opthalmologist. 

Rheumatic nodules occasionally appear under the skin, developing 
rapidly. They appear, as a rule, near the joints, and follow the course of 
the tendons. Sometimes they are painful on pressure. They may be from 
one to fifty in number, and may last for several weeks before absorption 
takes place. 

Prognosis. — Rheumatic polyarthritis in children tends to quick recov- 
ery. Relapses are common, and it is in these secondary attacks that the 
endocardium most often suffers. Fatalities may follow severe complications. 

Differential Diagnosis. — Septic arthritis as seen in scarlet fever and 
gonorrheal arthritis should be excluded, as should the rarer cases of pneu- 
mococcic arthritis. The history and the intense localization tending toward 
suppuration in the septic types will assist in making the diagnosis. A blood 
count in septic cases will show high leukocytosis. An exploratory puncture 
is often justifiable in establishing a prompt diagnosis. 

Scarlatinal polyarthritides, as a rule, affect the wrist-joints first, then 
the shoulders, knees, and feet. They appear in the second or third week 
of the disease, and last about one week unless suppuration sets in. 

Pneumococcic arthritis is seen usually in the first and second years of 
life as a sequel of a bronchopneumonia, or a lobar pneumonia. The pus 
contains cliplococci which stain by the Gram method. As a rule the 
affection is limited to one joint. 

Gonorrheal arthritis is rare in children, although often decidedly puz- 
zling from a diagnostic standpoint, unless evidences of a previous gonorrheal 
infection are obtained. It appears some weeks following the local attack. 
The knee-joints are, as a rule, primarily involved, but in children it is very 
apt to be polyarticular. The articulations, are extremely painful, there is 
a high irregular temperature and the effusion in the joints contains typical 
gonococci. 



THE INFECTIOUS DISEASES. 



291 



Syphilitic arthritis is symmetrical, and other evidences of the disease 
may be present. 

Cases of epidemic poliomyelitis which complain of intense pain have 
been mistaken for rheumatism. The loss of the patellar reflexes and the' 
electrical reaction will serve to distinguish them. 

Scurvy in infancy may occa- 
sionally be mistaken for rheumatic 
polyarthritis. The history, exami- 
nation of the gums, of the urine, the 
localization, and the X-rays will 
prevent a mistake in diagnosis. 

Treatment. Prophylactic. — 
Children predisposed to rheumatic 
fever or who have had an attack 
of rheumatic fever or chorea should 
avoid exposure to dampness or 
cold. The tonsils, if hypertrophied, 
should be removed. The diet must 
be carefully regulated and all forms 
of intestinal fermentation promptly 
treated. 

Management. — Eest in bed 
should be considered as the first 
and most important direction, and 
the patient should be kept in bed 
until all rheumatic manifestations 
have ceased. "Wearing of woolen, 
linen, or merino undergarments is 
to be recommended. 

The diet may consist of cereals, 
milk, paps, bread, and lemonade for 
the thirst. When the fever has 
passed, vegetables, eggs, and finally 
meats are allowed. 
Drugs. — The salicylates in the form of the sodium salts or. better 
still, novaspirin are effective remedies to control the attacks. Eest in bed 
and the early exhibition of the salicylates are the only weapons against the 
cardiac complications. Severe cases should have trebled doses of the sali- 
cylate given in a starch enema by rectum every six hours until effect is 
produced. 




Fig. 81. — Gonorrheal arthritis, com- 
plicating gonorrheal vulvo-vaginitis 
Polyarticular in distribution. 



292 DISEASES OF CHILDKEN. 

Novaspirin in doses of 2 to 5 grains three or four times daily to a five- 
year-old child should he persisted in for a week or more. 

Salol, aspirin, phenacetin, salipirin, and salophen (see Dosage, page 
64) may be substituted if the above remedies are not tolerated. 




Fig. 82. — • Chronic infectious polyarthritis. 

The tincture of the ehlorid of iron, five drops in water after meals in 
convalescence, is beneficial. However, if the diagnosis be correct, aspirin 
or sodium salic}date will give speedy relief. The joints should be enveloped 
in cotton wool. Immobilization with splints, especially with restless chil- 
dren, will often give considerable relief. An ice-bag is applied over the 
heart for an unduly rapid pulse or endocardial involvement. 



TILE INFECTIOUS DISEASES. 



293 



Infectious Arthritides. 
Following any of the acute infectious diseases, especially pneumonia, 
scarlatina and typhoid fever, there may result an active inflammation in the 
joints or neighboring bony structures. These arthritides result from bac- 
terial invasion in some instances, and in others are apparently the result of 
the toxic products of the underlying disease. Suppuration may occur, as 
evidenced by fluctuation and tenderness. Aspiration is then indicated and, 
besides relieving the joint, assists in establishing the diagnosis from a 
bacteriological standpoint. These cases do not react to the salicylates or 
their derivatives, and are to be distinguished by the greater degree and 
rapidity of the involvement and the tendency to suppuration. The tem- 
perature often assumes the wide variations seen in sepsis of any part of 
the body. 

Rheumatoids. 
Formerly these affections were classed under the head of chronic 
articular rheumatism, and much confusion has resulted from attempts 

to classify them as following or 
developing from rheumatic fever. 
One group of these cases 
often designated as villous ar- 
thritis results from thickening of 
the synovial sheath and an over- 
growth of the villi within the 
joint This affection may be 
mono- or polyarticular, and 
spreads, if at all. only slowly 
from joint to joint. As a rule, 
there is no fever, the joints 
assuming a swollen, waxy, shin- 
ing appearance. Tn cases of 
long standing the joints become 
more or less ankylosed and de- 
formities result. 

Arthritis deformans some- 
times occurs before puberty, hut 
it is rare. The teeth should be 
carefully searched for a possible 
focus of infection. Any focus of 
suppuration should be suspected. 
The characteristic features are 
The disease affects many joints at 




Fig. 83. — Arthritis deformans in an 
eight-year-old girl. 

joint deformity, pain, and disability 



294 DISEASES OF CHILDREN. 

one time and progressively involves others. The joints of the fingers are, 
as a rule, the first to be affected. Later there is seen much atrophy of the 
soft parts and even of the bones themselves. These chronic forms must be 
differentiated from tuberculous and syphilitic arthritides. Syphilitic affec- 
tions usually appear late in neglected cases and fortunately are rarely seen 
in children. There is an effusion of serofibrinous fluid into the joint, 
accompanied by little or no constitutional symptoms. The history, and 
sometimes a specific inflammation of the cornea, may definitely determine 
the diagnosis. 

Tuberculous arthritis is accompanied by bone changes, and the 
X-ray should be employed to clear up a case that offers any difficulties in 
diagnosis. The tuberculin reaction, inoculation experiments in animals, or 
the tuberculin tests, may also be employed as diagnostic aids. 

Treatment. — In the early stages, if there is any pain, rest in splints 
will afford much relief. As pointed out by Taylor, the diet should be nutri- 
tious and not restricted. Any focus of infection, as in the teeth, e.g., must 
be removed. Later massage and careful passive movements combined with 
baths sometimes lead to success. Orthopedic appliances and surgical inter- 
vention are often necessary to correct resulting deformities. 

Still's Disease. — This is a polyarthritis occurring in childhood which 
is as yet little understood. Clinically, it seems related to certain forms of 
chronic sepsis. 

There develops an enlargement and partial ankylosis of the joint with 
some temperature of an irregular type associated with splenic hypertrophy, 
and quite general enlargement of the liver and lymphatic glands. 

As distinguished from the other rheumatoids, the disease does not tend 
to destructive changes in the joints, and in fact seems to be self -limited. 

Malaria. 

(Paludism.) 
Malaria is an infectious disease caused by the hemacytozoon of Laveran, 
and characterized by a periodic intermittent or remittent fever. 

Etiology. — The parasite is carried through the anopheles mosquito, 
which is distinguished from the common mosquito or culex by the following 
characteristics. 

Anopheles. Culex. 

1. Two large palpi on side of 1. Small palpi. 

proboscis. 

2. Mottled wings. 2. No spots on wings. 

3. Body held at an angle 45° 3. Body held parallel. 

or more. Posterior legs often crossed 

over back. 

4. More often found in the 4. More often found in cities. 

country. 



THE INFECTIOUS DISEASES. 295 

The parasite of Laveran occurs in three forms : the tertian, quartan, 
and estivoautumnal. 

In the fall of the year the greater number of cases are seen. Eegions 
in which much marsh land is found are favorable places for the breeding 
of the anopheles, and in these localities malaria is naturally more prevalent. 

Pathology.- — The tertian variety develops in the human organism in 
forty-eight hours. At first there is seen a small ovoid particle within a red 
blood-cell. Pigmentation appears as development progresses around the 
periphery of the parasite. Ameboid movements may be noted. The hemo- 
globin of the red cell appears to be destroyed by the parasite. Segmentation 
now takes place, creating the spores which are freed in the blood stream 
and are ready to attack new red cells, and then pass through a similar cycle 
of development. 

The quartan type completes its development in seventy-two hours, pro- 
ducing the characteristic paroxysms on the fourth day, instead of on the 
third, as in the tertian type. 

It may be differentiated from the tertian by the lack of movement on 
the third day, and by the peculiar yellowish-green color of the cell, and by 
the rosette appearance on the fourth day. 

The estivoautumnal variety takes twenty-four to forty-eight hours to 
complete its cycle, and cresentic forms appear after a week of development. 
The parasite is sparsely pigmented and smaller in size. The gametocytes 
or sexually differentiated types develop only in the intermediate host. 
Sporozoids develop in the host or mosquito, and through its salivary glands 
infect the bitten individual, where they develop into parasites and pass 
through one of the cycles as just described. 

In mild cases of malaria little alteration in the body structures may 
be found besides an enlarged spleen and changes in the blood. Malaria is 
rarely fatal in infants and children. 

In the pernicious forms both the liver and spleen are enlarged. In 
chronic malaria the spleen and sometimes the liver become hard and deeply 
pigmented. 

Symptomatology. — In infants (in whom it is quite rare) and in 
younger children the symptoms are irregular in form and the clinical diag- 
nosis is often obscure. In older children the typical adult type is seen, 
presenting little or no difficulty in diagnosis. A distinct chill or chilly 
sensations, and sometimes a convulsion, may usher in an attack. Chills are 
not observed in infants. 

The child has been listless for several days or complains of being tired, 
stretches, and yawn?. The extremities are cold, and the child seeks its bed 
for warmth. 



296 DISEASES OE CHILDREN. 

The common type in infants and younger children results from a double 
infection with the tertian parasite, producing the so-called quotidian fever. 
The temperature is high, with a corresponding pulse rate. 

The estivoautumnal type is not often met with; it produces a very 
irregular form of fever with or without a definite paroxysm. The fever may 
be intermittent or even remittent in type; that is, a continuous fever with 
small excursions and no drop to the normal. 

In older children, as has been said above, the adult type is simulated. 
The period of chill is followed by the stage of fever and more or less per- 
spiration. The temperature reaches 104° or 105° F. and is accompanied 
by headache, often vomiting and extreme thirst. A normal or subnormal 
temperature follows after the period of high fever. The succeeding day a 
robust child may be willing to go about and play as usual. 

In the cities we see a subacute variety, usually in children, about the 
fifth year of age. They are brought because they are on different days list- 
less, pale, and without ambition. The physical examination often shows 
an enlarged spleen and characteristic blood changes. True chills are not 
experienced nor does one obtain a history of fever followed by perspiration. 

Malarial cachexia and the pernicious forms of malaria are rarely seen 
among children in the United States, at least in the North. In the cachectic 
or chronic type the spleen is uniformly large and firm, sometimes extending 
to the crest of the ilium. In these cases the liver is apt to be enlarged. 
The child is extremely anemic, has a greenish-yellow tinge, and a poor com- 
plexion. Loss of appetite and constipation are commonly found. The 
urine is highly colored and may contain casts and blood. 

Differential Diagnosis. — Malaria must be differentiated from typhoid, 
secondary anemia, Banti's disease, and certain forms of nephritis. Repeated 
examinations of a fresh or stained specimen of blood, or both, should be 
made for evidences of the malarial organism. 

The therapeutic test with quinin may be made in suspected cases in 
which a blood examination is not feasible. A 20 per cent, increase in the 
large mononuclear leucocytes usually means a protozoal infection. 

The uniformly enlarged spleen found in malaria is a diagnostic feature 
of great importance. The spleen is said to be enlarged in a child when it 
can be felt. The Wiclal test and a differential blood count will often assist 
in fixing the diagnosis when a careful physical examination, including the 
ears, has been made to exclude other conditions. Pyelitis is excluded by a 
urinary examinati on . 

Treatment. Prophylactic. — The physician should be acquainted 
with the genus of mosquito in his locality. If the anopheles are present he 
should insist upon the authorities taking all possible measures to drain the 



THE INFECTIOUS DISEASES. 297 

swampy areas. The children's cribs should be closely screened. Water bar- 
rels and similar tanks must be protected by screens to prevent the develop- 
ment of larvae. The latter may be killed by the use of crude petroleum 
floated over infested pools. 

Therapeutic. — An initial purge with calomel is recommended. The 
early and continued use of quinin until a cure is effected is essential in an}- 
of the forms above mentioned. Relatively larger doses may be given to 
children than to adults. For infants and younger children, the soluble 
bisulphate is recommended. Its bitter taste is often less objected to by 
younger children than by their elders. The syrup of verba santa best dis- 
guises its bitter taste if any addition is necessary. Euquinin and tannate 
of quinin are tasteless preparations which may be given in mild cases, and 
when given should be prescribed in doses double that of the sulphate. The 
sulphate of quinin in half -grain doses may be made more palatable by the 
use of chocolate in tablets or lozenges. 

The year-old child may be given one grain of the sulphate or bisulphate 
every three hours. A child of five years, three grains every four hours. 
Larger doses may be given on well days, and decreased or omitted during 
the paroxysms. Where the stomach is irritable and the quinin not retained, 
rectal injections of the bisulphate may be made, preferably in a mucilaginous 
suspension. 

Suppositories of quinin are not very satisfactory for continued usage. 
The hydrochlorate or bimuriate of quinin in cocoa-butter should be used for 
this purpose. The hypodermatic administration of quinin in children in 
this country is unnecessary and uncalled for. 

The chill is combated with a number of hot-water bottles, a hot pack or 
a hot bath. The oncoming fever is allayed with alcohol sponging and cool 
drinks in small quantity at frequent intervals. 

Quinin should be administered for at least a week following the last 
symptoms of malaria. The elixir of iron, quinin and strychnia will do 
much to combat the resulting anemia, a half-dram three times a day after 
meals to a five-year-old child. Fowler's solution or Warburg's tincture are 
useful in the long-standing cases. 

Erysipelas. 

This is a constitutional infections disease presenting a diffuse, rapidly 
spreading inflammation of the skin and subcutaneous connective tissue, and 
occasionally of the mucous membranes. 

Etiology. — Xo specific organism has been found in erysipelas, hut a 
streptococcus is thought to be usually the active cause. It may occur in 



298 DISEASES OF CHILDREN". 

connection with a septic condition of the mother during or shortly after 
birth, or from contamination in lying-in hospitals or midwives. The virus 
enters the system through an abrasion of the skin or mucous membrane. 

Symptomatology. — > The disease is more apt to occur during infancy 
than childhood, and the earlier it appears after birth the more serious will 
be its effects. In robust infants the inflamed skin will present a deep-red 




Fig. 84. — Erysipelas, which began on the face and spread over the body. 

color, while in feebler babies it will be lighter, presenting more of a pinkish 
appearance. The deeper tissues may likewise be involved in a phlegmonous 
inflammation in severe cases, and there may also be edema and finally some 
desquamation. In the newly-born the disease is apt to be contracted from 
some septic condition of the mother. It may then start at the umbilicus, 
in the genital region, or from some point of abrasion consequent to the 
delivery. Where the umbilicus is affected, the disease is apt to extend 






THE INFECTIOUS DISEASES. 299 

inward, producing a peritonitis. In other cases pneumonia or empyema 
may ensue and hasten the fatal ending. In older infants the disease 
begins on some abrasion of the skin, frequently around the genital organs, 
but sometimes on the trunk, arms, or legs. It is not so apt as in adults to 
attack the face and scalp. The cutaneous redness and subcutaneous infil- 
tration spread rapidly, but with a sharp line of demarcation between the 
diseased and healthy skin. The affected part is usually hot to the touch. 
The constitutional symptoms are commonly severe, with evidences of 
prostration. The result of the pricking or burning pain is seen in great 
restlessness, disturbed sleep, and occasionally convulsions. The fever is 
irregular and high up to 105° F. where much of the skin is involved. The 
pulse is usually rapid and feeble. There may be evidence of gastroenteric 
irritation, shown either by vomiting or diarrhea. In fatal cases death 
usually results from exhaustion or from some complicating disease, such as 
peritonitis or pneumonia. Abscesses and even sloughing of tissues may 
accompany severe and deep-seated erysipelas. The tendency to spread is 
shown in some cases by the whole surface of the body becoming involved. 
There is frequently in infants a recurrence of the inflammation involving 
the same surfaces as were originally attacked. The disease may last from 
one to three or four weeks. 

Prognosis. — The prognosis will vary with the age of the infant and 
the extent of the inflammation. It is very fatal during the first month, 
and from that period up to the sixth month the outlook will be uncertain. 
After six months the prognosis is good. Constitutional symptoms are usu- 
ally less severe when the arms and legs are involved than when the disease 
affects the region around the umbilicus or the neck and head. If the 
inflammation is superfical and spreads slowly, the prognosis is naturally 
more favorable than where it spreads rapidly and is more deep-seated with 
the character of a cellulitis. 

Treatment. — While the disease cannot be aborted, every effort must 
be made to sustain the strength of the infant by simple, nourishing diet. 
If the mother is septic, the baby must be removed from the breast, but 
otherwise maternal feeding offers the best chance for recovery. In bottle 
babies it may be necessary to weaken the formula, or to peptonize when 
there are evidences of digestive disturbances. AYe believe that tincture of 
the chlorid of iron is beneficial, and an infant of a year old may be given 
three or four drops, well diluted, every three hours. As it is an asthenic 
disease, it is often necessary to stimulate, giving strychnin or whiskey when 
the pulse is weak. Cooling and antiseptic applications may be applied to 
the skin and such as the Iiq. alumini acetatis X. F. or a 50 per cent, solution 



300 DISEASES OF CHILDREN. 

of magnesium sulphate. Ichthyol, a dram to the ounce, may be employed 
to relieve itching and burning and act as a local antiseptic. Infants with 
erysipelas should be isolated, particularly when near surgical cases or those 
apt to have any abrasion of the skin or mucous membranes. Their clothing 
and bedding should be disinfected at the termination of the disease. 

The polyvalent streptococcic serum may be tried in desperate cases, 
but our experience with its use prevents its recommendation as a general 
remedial measure. 

Disinfection. 

Disinfection in the light of our recent conception of the transmission 
of infectious diseases no longer plays a prominent part. Sunlight and 
fresh air are alone depended upon for the disinfection of the room and for 
such contents as cannot be burned. The contagion is carried not by the air, 
but by the secretions from the body cavities, or by insects. Except when 
there is close contact with the patient the danger of transmission is com- 
paratively slight. The wearing of cap, gown and rubber gloves amply 
protects the physician in this regard. 

The Sick-room in Infectious Diseases. — Infection may be carried 
in the sputum, in the throat secretions, in discharges from the nose and 
ear, in skin debris, in exudations, in conjunctival or abscess discharges, 
and in the urine or stools. The sick-room should be stripped of superfluous 
fittings; it should be in a remote part of the house, and preferably on the 
top floor. A large room with plenty of ventilation and sunshine and with 
an open fire should if possible be selected. A gown and hood should be 
provided for the physician and hung in a separate outside closet. All 
clothing worn by the attendants in the sick-room should be washable, and 
a complete change should be made before mingling with the members of 
the household. When changes in linen are made for the patient or attend- 
ant the articles are to be rolled up in a bundle and put to soak for twenty- 
four hours in a carbolic (1 to 20) solution before being sent to the laundry, 
where they are to be washed separately. 

When it is known that anyone has been exposed to an infectious disease, 
they should be isolated as soon as possible and given a bichlorid of mercury 
(1-5,000) bath and a complete change of clothing. Such individuals 
should be kept under close observation until the incubation period for that 
particular disease has passed. 

Scrupulous cleanliness with regard to the excreta and discharges of 
the patient is imperative. Soft Japanese paper napkins are most convenient 
for wiping nose and throat discharges. They must be burned at once after 



THE INFECTIOUS DISEASES. 301 

use. Carbolic vaselin rubbed over the skin of patients suffering from var- 
iola, varicella and scarlet fever prevents the pus, exudations, and epithelial 
debris from drying and being scattered. Urine and stools should be treated 
with equal volumes of carbolic acid solution (1 to 20), bichlorid of 'mer- 
cury (1 to 1.000) or chlorid of lime (1 to 50), and allowed to stand three or 
four hours before disposing of them. Large masses in stools should be broken 
up to insure thorough disinfection. In cases in which the throat is involved, 
frequent gargles of chlorin water, potassium permanganate (1 to 300), 
formalin 1 per cent, or peroxid of hydrogen reduce the number of bacteria 
in the expired air besides having a beneficial effect on the patient. Dishes 
and utensils used by a patient are to be placed for an hour in a large 
receptacle containing carbolic solution (1 to 20) and then boiled or scalded. 
Milk bottles should not be returned to the dairy but destroyed. 

The remains of one dying of an infectious disease should be em- 
balmed with a fluid which will stand the bacteriological test. Close all 
external openings of the body with absorbent cotton and give a thorough 
sponge bath (including the hair) using carbolic solution (1 to 20) or 
bichlorid of mercury (1 to 1,000). 

Carbolic acid in a one to twenty or 5 per cent, solution will rapidly 
destroy non-sporing bacteria, although their spores are not destroyed for 
aereral weeks. Albumin, if present, impairs its efficiency only slightly. 
Cresol, a derivative of carbolic acid, is also an excellent disinfectant. 

Calx Chlorata (chlorid of lime) depends upon the formation of hypo- 
chlorous acid for its efficiency. The alkalinity of the lime present renders 
a solution of this agent most valuable for disinfecting albuminous material, 
a* it first disintegrates and then disinfects. For practical purposes, no 
other chemical can compare with this agent for the disinfection of sputum 
and feces. If equal parts of a dilute solution of acetic acid (1.25 per cent.) 
or vinegar and a saturated solution of chlorid of lime are mixed together 
this agent will destroy spores in one minute. Chlorid of lime rapidly de- 
teriorates if left uncovered, due to liberation of the hypochlorous acid. 
Herein lies the greatest objection to tin's agent, for much of the chemicals 
sold in the shops i< too old to be efficient. 



CHAPTER XXII. 
TUBERCULOSIS. 

Tuberculosis is an infective fever caused by the toxins of the tubercle 
bacillus, and characterized by the formation of heteroneoplasms called 
tubercles. Any organ or part of the body may be attacked. The disease 
may be confined to certain organs or may be generalized, occurring at the 
same time in many parts of the body. 

Etiology. — The tubercle bacillus upon which tuberculosis in any 
or all of its manifestations depends, is a rod-shaped, facultative, colorless 
bacillus, slightly bent and having rounded ends. In size it is about one- 
fourth to one-half the diameter of a red blood-cell. It is especially distin- 
guishable for its staining properties. It strongly resists decolorization after 
having been stained with acid dyes. 

There are several varieties of the bacillus. We are mainly concerned 
here with the human and bovine types. The controversy regarding these 
types is not yet settled, but the distinction still seems to be a strong one 
between these forms. 

The bovine type of bacillus differs somewhat in form, being more irreg- 
ular, thicker or oval in shape with blunted ends. The types may also be 
differentiated by cultural methods. This method, however, is suitable only 
for a laboratory specialist. About 10 per cent, of all tuberculosis in early 
life has been demonstrated to be caused by the bovine type. Pulmonary 
forms are rarely of bovine origin. 

The bacillus is easily destroyed by sunlight or heat, either dry or moist, 
but is not affected by low temperatures. 

The disease occurs at all ages — fetal tuberculosis has been recorded 
(Jacobi, Wollstein, and others). 

The invading microorganism gains entrance to the body through three 
main channels, given in the order of their relative importance ; through the 
respiratory tract, through the intestinal tract, and through wounds and 
abrasions of the skin. Infants and children are infected mainly through 
the respiratory tract. 

Hereditary predisposition is still the subject of argument, but the posi- 
tion held by Adami appeals to us. He believes that two possibilities may 
result from parental tuberculosis; the offspring may become especially 
susceptible if the germinal cells become weakened by progressive disease, or 
if the disease is well resisted the child may acquire an increased resistance 
to the disease. 

302 



TUBERCULOSIS. 



303 






Parental diseases, nutritional faults and developmental defects in the 
parents often leave the offspring with a lowered resistance to tuberculosis. 

A child with poor muscular development, with a flat and narrow chest 
and small abdomen is considered to have a disposition to tuberculosis; we 
can add to this class children who are mouth-breathers and have defects of the 
nose and mouth. 

In childhood there is little 
resistance to the disease; the 
glands, meninges, bones, joints, 
and lungs are easily invaded and 
are believed by v. Behring often 
to remain latent and develop in 
later life into the pulmonary 
form. 

Again, in childhood the dis- 
ease is not apt to develop at the 
site of infection as in adults, but 
extends to other tissues and forms 
tubercles there. The entity known 
as scrofula is still acceptable to 
Continental Europe ; but in Amer- 
ica the weight of opinion is that 
scrofula indicates tuberculosis, and 
we believe with Baldwin that it 
can be used to mean an important 
predisposition to pulmonary tu- 
berculosis, which he says is asso- 
ciated with it in 25 per cent, 
of all cases. ^Measles, whooping 
cough, diphtheria, pneumonia, in- 
fluenza and, in a lesser degree, 
scarlet fever, tonsillitis, and vari- 
ola are often the precursors of 
tuberculosis, because of their ef- 
fect on the mucous membranes and 
lymph glands accompanied by the lowered resistance of the convalescent child. 
Rickets, too. is a disease favoring tuberculous infection when accom- 
panied by defective nutrition and thoracic deformities. Finally, gastro- 
intestinal diseases from their destructive action on the mucous membranes 
lead sometimes to open infection and probably often to the latent form. 




Fig. 85. — Conformation of the chest 
commonly seen in tuberculous children. 



304: DISEASES OF CHILDREN. 

The children of poor parents in unsanitary surroundings, whether in 
city or even in the country, are prone to the infection, which they may 
receive from the following sources: Human sputum, through food objects 
or dust, urine or feces on soiled clothing or beds, and milk of tuberculous 
cattle. Milk as a food, however, may be indirectly contaminated by dust or 
infected containers. Infants at the breast have been infected by their 
mother's soiled hands or her kisses. 

Cornet reports infection by midwives who blew into the mouths of the 
infants to start up respiration. 

Children are intimately connected with the fact that tuberculosis is a 
" family disease " — 40 to 60 per cent, disclosing a history of other cases in 
the household; and this close contact is the great infecting method: the 
nursling infected by close touch with its mother, the creeping infant on the 
contaminated floor carrying all things to its mouth, the school boy trading 
toys — all show at a glance the numberless ways in which children may 
become tuberculous. 

Tuberculous Adenitis. 

This may be confined to certain groups of lymph-glands, as the cervical 
or bronchial, or there may be an involvement of all, or nearly all, the lymph 
nodes of the body. 

The glands become infected by access of tubercle bacilli through the 
lymph channels. The point of entrance may have been only a slight 
abrasion or some form of dermatitis. The glands may also become infected 
from tuberculous lesions in their vicinity. 

A cross section of a tuberculous gland shows the parenchyma swollen 
and hyperplastic, grayish in color, containing nodules varying in size, some 
of which are undergoing caseation. If the latter process is advanced, the 
gland is soft and the tubercles are found at the margins only. The glands 
most commonly involved are those at the root of the lung. The mesenteric 
lymph nodes are frequently infected in children and are the usual accom- 
paniment of the miliary and generalized forms. 

Symptomatology. — The subjects of tuberculous adenitis are, as a rule, 
anemic children of the blond type. The appetite is capricious or lost, the 
weight decreases, and at this time the parent may notice an enlargement of 
a gland or group of glands. They are not painful to the touch, growing 
slowly but steadily; sometimes there is a rise of fever, especially in the 
evening. Physical examination may show tuberculous lesions elsewhere in 
the body. If the cervical lymph nodes are involved the tumors are at first 
found in relation with the sternocleido mastoid muscle. At first they are 



TUBEKCULOSIS. 



305 



freely movable, but the chain of glands increasing, they soon adhere one 
to the other, forming sometimes large masses which may even cause me- 
chanical obstruction. Bilateral involvment is not uncommon. The overly- 
ing skin now becomes attached to the mass below, and when the glands 
caseate the skin is thickened and loses its normal color, often becoming 
purplish-red. If there is no surgical intervention the glands rupture 
through the overlying skin or dissect the fascial planes; the abscess may 
discharge at some distant point. Often several long-persisting fistulous 
tracts result. 




Fig. 86. — Tuberculous adenitis of the cervical and axiliary glands. 



In the generalized form, the cervical, inguinal, and axillary glands 
show the greatest and earliest involvement. The children are markedly 
anemic and often have a variable amount of temperature. Wasting slowly 
takes place and new foci are found developing in other parts of the body. 
Bimanual rectal examination will show the involvment of the retroperitoneal 
and mesenteric lymph nodes. 
20 



300 DISEASES OF CHILDREN. 

When the bronchial lymph nodes are large, pressure symptoms may 
occur, causing a paroxysmal cough with breathing signs of bronchial 
asthma. In advanced cases dyspnea is produced on slight exertion. Some- 
times dullness is obtained on percussion over the manubrium which extends 
over a varying area. This is usually accompanied by tubular breathing on 
the left side. 

Diagnosis. — The diagnosis of tuberculous adenitis is based upon the 
slow course and the absence of active inflammatory changes, such as heat 
or pain on palpation. Simple adenitis can usually be traced to some source 
of infection, as an eczematous area, caries of the teeth, etc. These glands 
subside when the focus of irritation is removed. If there are evidences of 
tuberculosis in other structures, tuberculous adenitis may be suspected. 

The tuberculin tests (p. 56) may be used to corroborate the diagnosis. 
Syphilitic glands are distinguished by their location. The epitrochlear 
glands show simultaneous enlargement with other syphilitic manifestations 
in different parts of the body. 

Lymphosarcoma is sometimes confounded with generalized tuberculous 
adenitis. This disease usually primarily involves the retroperitoneal glands 
or those within the mediastinum. The growth here is rapid, invading neigh- 
boring structures, and often producing serious symptoms before the true 
nature of the disease is suspected. 

Course and Prognosis. — It is often difficult to predict the end-result 
of a tuberculous adenitis. The prognosis should always be considered ser- 
iously as a focus which may at any time spread the disease to the lungs or 
other structures. 

If the subject is young and can be placed in favorable surroundings, 
restitution to the normal may take place. Even degenerated glands with 
fistulous tracts may eventually terminate in a cure under proper care. 

Treatment. — Immediate steps should be taken just as soon as the 
diagnosis is certain to remove the child, if possible, to the seashore, where 
it should live in the sunshine and fresh air. The diet should be as nourish- 
ing as possible, consisting principally of milk, eggs, cereals, and rare meats. 
Cod-liver oil, if well borne, should be given twice a day, after the midday 
and evening meal. If this is not acceptable, good results can be obtained 
by increasing the quantity of butter, cream, or top milks. Sometimes olive 
oil in two-dram doses twice a day can be substituted if the child prefers it. 

Surgical removal of the glands may be considered when they are super* 
ficial and movable. The dissection is often long, tedious, and dangerous 
when the glands are deep and are in proximity to the great vessels. General 
miliary tuberculosis may follow the removal of glands when a clean dissec- 






TUBERCULOSIS. 307 

tion is impossible. However, it is sometimes necessary to resort to removal 
for the cosmetic effect or for the relief of pressure symptoms. Good results 
have been obtained in a number of cases from radiotherapy and it would 
seem best to counsel non-interference until these measures have been given 
a fair trial. 

Thoracic Tuberculosis. 

It is only within recent years that the frequency of pulmonary tubercu- 
losis in early life has been correctly appreciated. From a study of all 
necropsies in children under fifteen years of age, Harbitz at Christiana 
found tuberculosis in 42.5 per cent, of all. Denning shows that 70 per cent, 
of all infants and children who die from tuberculosis show tuberculous 
changes in their lungs. Pediatrists incline toward the respiratory tracts, 
while pathologists lean toward the alimentary tract as the principal portal 
of entry : the controversy, with much to be said on both sides, concerns us in 
regard to prophylactic measures to be spoken of below. 

Tuberculosis in early life increases regularly with the age. It is rare 
in the first three months of life, and then almost, month by month, the fre- 
quency increases steadily. The figures of Hamburger and Sluka, obtained 
from 2,557 necropsies on tuberculous children under fifteen years, report that 
tuberculosis was the direct cause of death in all those under six months of 
age ; that it caused death in 75 per cent, of those in the second year of life, 
and in the children over two years old it became more infrequently the cause 
of death. Xecropsy findings, however, are not absolute indications of the 
prevalence of tuberculosis in early life since virulent bacteria may be present 
without producing demonstrable lesions. 

Tuberculosis in early life is a disease of the lymph nodes, but after 
the tenth year the pulmonary form is more prevalent; and again after 
adolescence the characteristics do not differ greatly from those seen ir_ 
adults. 

Pulmonary involvement may occur by direct infection from caseous 
tuberculous glands through the blood stream or by emboli, and through the 
lymph channels from tuberculous lymph nodes, bones, or pleura. 

Pulmonary Lesions. — The pathological anatomy does not differ 
greatly from that seen in adult life, but the areas involved are always 
greater; in other words, the disease is more diffuse. This is especailly true 
in the first two years of life. 

In TUBERCULOUS BRONCHOPNEUMONIA, which is the predominating 
arid fatal form, there occur large caseating deposits usually to some extent 
in both lungs. When a mixed infection occurs the nodules are very apt to 



308 DISEASES OF CHILDREN. 

degenerate. True cavities of any size, however, are rarely seen in early life. 
The glands at the root of the lung are invariably enlarged and often soft 
and caseating. The pleura is almost always involved. 

In miliary tuberculosis of the lungs, the tubercles are scattered over 
the surface of the lung, and in some cases have been found in the paren- 
chyma. Patches of bronchopneumonia and congestion with edema may be 
present, or the lung may appear quite normal except for the superficial 
tubercles. 

Diagnosis. — The diagnosis of incipient tuberculosis of the lungs dif- 
fers considerably in early life from that of adults. In the first place the 
apices of the lungs are not most frequently involved ; it is the lower lobes or 
the lower part of the upper lobe that is primarily involved, which may often 
be accounted for by the proximity of the bronchial glands. The physical 
signs often do not differ from those obtained in bronchitis and broncho- 
pneumonia, and the younger the child the more diffuse will be the disease. 
Therefore it is necessary to employ every means at our command to perfect 
the diagnosis. The physical signs with the symptoms and the history then 
become of value. 

In obtaining a history in suspected children, it is especially important 
to ascertain if the child has been in intimate or close contact with a tuber- 
culous patient, or if there has been a slow convalescence from any of the 
infectious diseases, especially measles and pertussis. 

Gibson has called attention to a venous dilatation occurring over the 
chest, neck, and shoulders of children, and tending to converge above the 
sternum. This, when present, is a valuable sign, and it is probably due to 
tuberculous bronchial lymph nodes. If we could safely and surely diagnos- 
ticate enlarged bronchial lymph nodes we would have valuable confirmatory 
evidence. D'Espine says he has a reliable method in voice auscultation ; in 
the healthy child the tracheal tone stops at the seventh cervical spine, but 
is heard below this point in pathological conditions. Later on, dullness 
over the seventh cervical or first dorsal vertebra with intrascapular dullness 
may be elicited. Cavity formation is rarely recognized under three years of 
age, while after eight the signs will simulate those in the adult. Expector- 
ation is the exception in children, while under seven years hemoptysis rarely 
occurs and practically is never observed in those below five years old. 

Three groups of thoracic tuberculosis may be distinguished in children ; 
the glandular, tracheobronchial, and the pulmonary. The symptoms are 
never so characteristic as in the adult; as a rule, there is a rapid develop- 
ment of symptoms. If we encounter steady emaciation, progressive 
muscular weakness, an irregular temperature with a fairly constant evening 



TUBERCULOSIS. 309 

rise, enlarged superficial glands, with a persistent dry cough, we are justified 
in utilizing diagnostic aids to confirm the diagnosis. 

In adults, a diagnosis may sometimes be made by physical signs before 
the tubercle bacilli are found in the sputum. In infants and young chil- 
dren, however, we are pleased if we obtain any sputum to examine, and 
must be prepared to make diligent search for the bacillus. Among the 
methods used with success in obtaining sputum from infants is wrapping a 
piece of gauze on the end of the finger and irritating the epiglottis thus 
catching the sputum. We use an ordinary laryngeal swab wrapped with 
cotton which is quite effective and does no damage to the delicate mucous 
membranes. The sputum being often swallowed, the vomitus or the feces 
will also contain the bacilli, but the search is more arduous. 

Ogilvy and Coffin, as a result of their studies, believe that the difficulty 
and tedious technic of estimating the opsonic index and the wide variation 
obtained by various observers make this procedure impracticable for 
diagnosis. 

Injections of tuberculin may be used diagnostically as a last resort 
if it is imperative that a definite diagnosis be made. In children the reac- 
tion is more favorable than in adults. Its use, however, is limited to those 
cases without temperature. The dose which is safe in children is one ten- 
thousandth of a c.c. of Koch's old tuberculin, one three thousandths being 
the maximum dose. 

The agglutination and the heated serum tests have been tried, and the 
reports are quite uniformly against their practical value. 

The von Pirquet skin test (see p. 56) has superseded all the other 
tests for reliability. 

Pulmonary Tuberculosis. 

Acute and Subacute Forms. — Etiology. — Mainly through the bron- 
chial lymph nodes, the infection is carried to the lungs of infants and 
children ; the lung may be more directly affected, however, through the im- 
poverished mucous membrane following certain infectious diseases. Tuber- 
culosis in other structures predisposes to lung infection. The generalized 
process in the lungs is part, and usually the termination, of a miliary 
tuberculosis, while the localized process is most often found close to the 
bronchial glands. 

Acute tuberculous bronchopneumonia in infants and young children 
does not markedly differ in its physical signs from the simple broncho- 
pneumonia, but the period of illness sometimes lasting from two to six 
weeks must be suggestive. 



310 



DISEASES OF CHILDREN, 



The fever is generally lower and with smaller excursions than in the 
ordinary form until the toxemia itself produces high evening rises up to 
103° or 104° F. Loss of weight is slow but progressive. The appetite is 
capricious, the patient is irritable, easilv tired, and at times somnolent; 
the bowels are, as a rule, constipated, although diarrhea may periodically 
appear. 

The fever causes restlessness at night 
and in the morning. The body and 
clothing may show that sweating has 
taken place. The cough is paroxysmal 
in character, and is apt to be more fre- 
quent upon awakening. As the disease 
progresses, circulatory changes are evi- 
denced by cyanosis in the finger-tips 
and lips. Dyspnea is easily caused by 
slight exertion or coughing. Hemopty- 
sis is exceedingly rare in children. If 
death does not supervene, the affection 
may appear elsewhere, as in the brain, 
intestinal tract, or in the glandular 
structures. 

Physical Signs — These may not 
differ from the ordinary broncho- 
pneumonic type of the disease. Occa- 
sionally only are there signs of cavity 
formation, or well-developed signs of 
bronchial and peritracheal glandular 
hypertrophy. The latter signs, if ob- 
tainable, are of distinct diagnostic im- 
portance. 

The examination of the sputum, 
obtained with a laryngeal swab or from 
the stomach contents, urine, and feces, 
may reveal the presence of tubercle 
bacilli. 




Fig. 87. — Chronic pulmonary tuber- 
culosis in a five-year -old boy. 



Chronic Pulmonary Tuberculosis. 

This form is rarely seen under five years of age. In the cases that have 
come under our observation, the tuberculous process was extremely diffuse 
in character. The physical signs do not markedly differ from those of the 
adult type. 



TUBERCULOSIS. 



311 



Progressive loss of weight, night-sweats, extreme anemia with high 
leukocytosis, and frequent attacks of gastroenteritis are the symptoms which 
finally precede death. 

At any age the pleura may become involved in the tuberculous process, 
and an empyema result. The pus in these cases is thinner and more watery 
in consistency, and only rarely can the tubercle bacilli be isolated. These 
cases do not tend to recovery; further lung involvment takes place, and 
death often results with meningeal symptoms. 

Course. — The course of the disease in early life varies with the form. 
There is a latent form in which the characteristic features are irregular 
fever, rapid emaciation, and late pulmonary signs. The affection runs a 




Fig. 88. — Clubbed fingers in chronic pulmonary tuberculosis. 






speedy course, terminating sometimes in a few days to a fortnight. The 
child with the bronchopnuemonic or the more usual variety may live several 
weeks. In exceptional cases the patient has lived six months. The chronic 
form, under favorable circumstances, such as the modern sanatorium treat- 
ment gives a more favorable prognosis ; that is, there is a tendency toward 
arrest of the process. 

Acute Miliary Tuberculosis. 

This is an acute general infection with tubercle bacilli, occurring at 
any period of childhood. As a rule, it is secondary to some primary focus 
in the body, which may have been dormant for some time. 

Etiology. — Measles, whooping-cough, and tuberculous lymph nodes 
are the exciting causes. The disease occurs quite commonly in early life, 
especially the meningeal form or tuberculous meningitis. McCrae had 
fortv- three cases of generalized miliary tuberculosis in 417 autopsies on 



312 DISEASES OE CHILDREN. 

tuberculous individuals ; among these were fifty-five children. The meninges 
were involved in twenty-one, and the thoracic lymph nodes in thirty-three 
cases. 

Two forms of the disease are recognized — the general and local — , 
based upon the symptoms. 

In the general form the symptoms in the early stages are such as to 
simulate beginning typhoid. There is irregular fever with no character- 
istic curve, malaise, loss of appetite, slow emaciation at first, becoming more 
marked as the disease progresses. The pulse is increased out of proportion 
to the temperature. Rapid, shallow breathing is later followed by the 
Cheyne-Stokes type as the disease progresses, or if meningeal symptoms 
intervene. Vomiting is often an early symptom. 

The spleen is enlarged almost invariably and the liver, too, is often in- 
creased in size. A disturbing slight cough is generally present. The urine 
contains traces of albumin and hyalin casts, and occasionally tubercle bacilli 
can be found. Inoculation tests from the blood may confirm the diagnosis. 
The younger the child the more often does the meningeal form bring on a 
rapid termination. Delirium, stupor, and coma denote cerebral involvment. 
The usual course is from three to six weeks. The prognosis invariably is 
hopeless. 

Differential Diagnosis. — The Widal test and the more typical tem- 
perature curve, with the characteristic eruption, plus the relative increase 
in the mononuclear elements in typhoid, must be depended upon to dis- 
tinguish this form of tuberculosis from typhoid, although this is sometimes 
extremely difficult. In miliary tuberculosis, besides the tuberculin test, an 
ocular examination may, especially in the later stages, show tubercles in the 
choroid, or fluid withdrawn from the spinal canal may show tubercle bacilli. 

Local Manifestations. — Miliary involvment of the lungs usually occurs 
after measles or whooping-cough, or is secondary to a bronchopneumonic 
process. The physical signs offer no help in differentiation. The diagnosis 
in children is extremely difficult until the disease has progressed to some 
other structure, as the brain, when more characteristic symptoms are 
obtainable. 

Tuberculous Meningitis. 

The tubercle bacilli spread from some focus of infection through the 
lymph channels or blood current to the meninges, and usually form an 
eruption of miliary tubercles at the base of the brain, spreading up to the 
vessels in the fissure of Sylvius. An inflammatory exudate is almost in- 
variably found in the space between the optic chasm and the peduncles. 



TUBERCULOSIS. 313 

The exudate is yellowish-green in color, tenacious and adherent to the pia 
mater. The ventricles are more or less distended with fluid, in some 
instances forming a distinct internal hydrocephalus. The ependyma, if 
carefully removed, is found to be rough, edematous, and may be infiltrated 
with tubercles. The pia mater is injected with a serofibrinous or seropuru- 
lent infiltrate. Not infrequently the tubercles are seen in the choroid 
plexus. Occasionally there is only a slight amount of exudate, and the 
infection is found to be localized in the form of one or more nodules, some 
the size of hickory-nuts, which are known as solitary tubercles of the brain. 

Etiology. — Tuberculous lymph nodes which have become diseased 
as a result of the acute infectious diseases, especially pertussis and measles, 
play the principal role in the causation. A latent tuberculous focus may 
set free the tubercle bacilli into the blood stream. A tuberculous osteitis 
or an infection in the uropoietic system may be responsible for the menin- 
geal involvement. A number of cases seem to be traceable to a chronic 
otitis media. Unsanitary surroundings, especially in a tuberculous environ- 
ment, predispose to the disease. On the other hand, it occurs among the 
well-to-do, and may attack a child that has been considered exceptionally 
healthy. It commonly occurs below the age of five years. Infants of five 
months have been reported who have died of the disease. (Eilliet.) In 
Koplik's series of fifty-two cases, eleven were less than one year old, while 
the average age was slightly over four years. 

Symptomatology. — It is impossible to give a typical description of 
the symptoms of this disease, so varied are its manifestations. 

The prodromal symptoms usually come on gradually and insidiously. 
A previously healthy child becomes irritable, morose, and refuses to play. 
Lassitude, coated tongue, loss of appetite and occasional vomiting are, as a 
rule, attributed to digestive disturbances. If the child is old enough, head- 
ache, dull in character, is complained of. Progressively the symptoms grow 
more marked until signs of cerebral irritation appear. Occasionally the 
onset is abrupt with fever, vomiting, and pressure symptoms. 

The diagnosis may not be suspected until the child refuses to leave 
the bed. The pulse rate in infants is usually increased; in older children 
it may be irregular in character. Vomiting occurs irregularly and with no 
regard to the food ingested. The temperature is not high, rarely over 
101° F., and may be normal during the morning hours. The mentality is 
dulled and the child is aroused with difficulty. The food is taken without 
protest or interest. Infants may show increased tension by a bulging 
fontanel. A high-pitched scream, which if once heard is easily recognized 
and known as the hydrocephalic cry, often accompanies the headache which 



314: DISEASES OF CHILDREN. 

may now be intense. Except in infants, the abdomen becomes flat or sunken 
in the later stages, forming the so-called scaphoid abdomen. Constipation 
is the rule. Kigidity of the muscles of the neck may be noted, but distinct 
retraction may never occur or only in the final stages. There may now 
supervene irregular or associated ataxic movements. The respirations are 
slow and irregular, with the inspiration prolonged and sighing. The pupils 
may be unevenly contracted and react slowly or not at all to light. Nystag- 
mus may be an early symptom, while conjunctivitis, strabismus, and ptosis 
usually appear in the final stage. Marked apathy with delirium and coma 
supervene. Occasionally convulsions may occur. The pupils are now 
almost constantly dilated. The extremities are rigid or spastic, although 




Fig. 89. — Tuberculous meningitis ; patient comatose. 

paralyses, monoplegic or hemiplegic in type, may appear before the terminal 
stage. The respirations tend now to the Cheyne- Stokes type. The final 
stage is usually known by the frequent convulsive seizures. The emacia- 
tion is now rapid, the pulse becomes small and irregular until the agonal 
stage. The eyes are sunken. Edema of the lungs may be found on physical 
examination. The rigidity of the neck is supplanted by paralyses in vari- 
ous parts of the body. Examination of the fundus usually shows an optic 
neuritis. The urine and feces may be involuntarily passed. The tempera- 
ture toward the end may rise to 105° or 106° F., or there may be a sudden 
drop to subnormal. 

The reflexes are usually inhibited in this stage. Kernig's sign and 
the Babinski reflex are present in about 50 per cent, of the cases. Mac- 
ewen's sign, or a tympanitic note on percussion over the ventricles, is 
obtained in those cases in which there is an internal hydrocephalus. If 






TUBERCULOSIS. 315 

obtained in children over two years of age, it is of value in establishing the 
diagnosis. 

Lumbar puncture is of great importance in making the diagnosis, and 
sometimes is the only practical method of making the specific diagnosis 
(see p. 51). In this form of meningitis the fluid frequently flows out 
under increased pressure ; it usually is clear and contains a greater amount 
of protein than normal. 

Fehling's solution occasionally is reduced by the fluid. If the proper 
technic is followed, the presence of tubercle bacilli can be demonstrated, 
although such expert labor should be placed in the hands of a trained pathol- 
ogist. Inoculation experiments into animals may also be made for con- 
firmation. Mononuclear cells, sometimes over 90 per cent., are present 
in the fluid. 

Course. — ■ The duration is usually from three to four weeks. Occa- 
sionally there are periods of apparent improvement, which may give rise to 
a false hope of recovery. On the other hand, cases have remained under 
our observation for many weeks with slow and progressive emaciation, finally 
terminating fatally. 

Diagnosis. — The slow onset, the lack of hyperesthesia, the slower pulse 
and respiration, and the type of temperature curve, with the aid of lumbar 
puncture, are the only definite means of differentiation from the cerebro- 
spinal type. 

Some intracranial diseases may in their incipiency lead to confusion 
unless the characteristic symptoms of a meningitis are sought for. 

Prognosis. — Although there have been several reported cures in cases 
in which tubercle bacilli were found after repeated lumbar punctures, the 
disease must be regarded as quite hopeless. 

Treatment. — . Quiet and rest, with bromids for the relief of the ner- 
vous symptoms, and lumbar puncture for the relief of intracranial pressure, 
with frequent repetition of this procedure, if followed by amelioration of 
the symptoms, are indicated. The diet, usually liquid, is taken in a bottle 
or may be given by gavage. Iodid of potash and inunctions of mercury 
have proved valueless in our hands. 

Tuberculous Peritonitis. 

Tuberculous peritonitis is a comparatively rare affection, although this 
variety of peritonitis is more frequently seen in childhood than the non- 
tuberculous forms, and a diagnosis, first as to the condition itself, and then 
as to its particular variety, is of importance because of the direct bearing 
on the prognosis and surgical treatment. The peritoneum may become 



316 



DISEASES OF CHILDREN. 



involved from a tuberculous focus in any part of the body. The disease 
is nearly always secondary and the infection is carried through the lym- 
phatics or blood stream. Bovaird in 125 cases of general tuberculosis found 
the peritoneum involved in 7 per cent. 

From an anatomical standpoint four forms are usually recognized — 
miliary, miliary with ascites, the ulcerative, and the fibrous variety. 

The miliary form is met with in cases 
of general infection. It is practically impos- 
sible to make antemortem diagnosis of this 
form. The tubercles are found scattered over 
the peritoneum and intestines in large or 
small numbers. Adhesions form, binding the 
viscera to themselves, to the neighboring or- 
gans, and the abdominal wall. On opening 
the abdominal cavity a serous or seropurulent 
fluid is found. The peritoneum is clouded 
and streaked with lymph. In older cases 
adhesions form. 

The Ulcerative or Caseating Form. 
— Postmortem findings in this variety show 
caseating foci in the peritoneum. Lymph or 
pus takes the place of ascitic fluid. The in- 
testinal coils are matted with flbrinoplastic 
deposits. The abdominal wall may also be 
found adherent to the intestines. Tubercu- 
lous masses are found scattered over the 
parietal and visceral peritoneum, while in 
some cases ulcerations occur. The glands are 
usually greatly enlarged, and may be found 
in sacculations filled with purulent fluid. 
Fistulous tracts may occur and perforate at 
or near the umbilicus. 

The fibrous form rarely gives evidences 
of an effusion. There is an abundance of 
lymph on a thickened peritoneum, studded 
with miliary tubercles. The peritoneal cav- 
ity may be completely obliterated by the dense matting and firm adhesions. 
Eolls of omentum are occasionally seen, covered with fibrous tissue. The 
intestines themselves adhere to each other. The characteristic of this form 
is a tendency to the formation of cicatrical tissue. 




Fig. 90. — The ascitic form of 
tuberculous peritonitis. 



TUBERCULOSIS. 317 

Symptomatology of the Special Forms. — Ascitic Form. — The 
symptoms ruay be very insidious. There is a slow but steady increase in 
the size of the abdomen, and constipation alternates with diarrhea. There 
may be vomiting, the appetite is capricious or lost. Careful examination 
may now elicit fluid in the abdominal cavity. 

The superficial veins over the abdomen and lower chest are prominent. 
There is an evening rise of temperature, and progressive emaciation is noted. 
Eectal examination may disclose peritoneal nodules and enlarged mesenteric 
glands. An acute form is occasionally seen in which the symptoms simu- 
late an inflammation of the small and large intestines. The fever is quite 
high, the abdomen rapidly becomes distended with fluid. The prognosis is 
better in the insidious form. 

Ulcerative Form. — The symptoms are those of various grades of 
enteritis. There is vomiting, constipation or diarrhea, abdominal pain, loss 
of appetite, with occasionally bloody stools. The fever is quite high, irreg- 
ular in type with occasional sweating, especially on exertion, and consider- 
able prostration. 

Percussion shows areas of dullness or flatness, alternating with areas 
of tympany. Bimanual rectal examination may give strong evidence of the 
matted condition of the intestines. Occasionally the stools contain blood. 
Pus may be discharged through openings near the umbilicus. Emaciation 
is extreme, and the end comes through asthenia. 

Fibrous Variety. — The symptoms come on very gradually with some 
colicky pains in the abdomen. The bowels are usually constipated. There 
is some distention of the abdomen. Nausea and vomiting or symptoms of 
obstruction may lead to a careful examination of the abdomen, and the 
masses or rolls of omentum with some intraabdominal fluid may assist in 
establishing the diagnosis. 

Diagnosis. — A child between the ages of one and six years, who has 
lived in an environment of tuberculosis or whose vitality has been lowered 
by an infectious disease, and who is languid, peevish, and has an evening 
rise of temperature with some enlargement of the abdomen, should be care- 
fully examined for tuberculous peritonitis. The child may present the 
phthisical habitus or only appear to have lost some flesh. The skin is almost 
constantly dry and harsh. Passing the hand lightly over the abdomen, 
subcuticular nodules about the umbilicus are often felt. Fluctuation may 
be readily made out, or a suspicion of fluid only may be found on palpation 
and percussion. Bimanual rectal examination in the semirecumbent posi- 
tion should now be made to confirm the presence of fluid and to further 
ascertain the condition of the intestines, whether they are free or bound by 
a fibrinoplastic exudate. One accustomed to the normal conditions as found 



318 DISEASES OF CHILDREN. 

by the examining finger in children will appreciate the changes produced 
by a plastic exudate, and may furthermore feeL hypertrophied mesenteric 
lymph nodes and a band of adhesions running transversely across the abdo- 
men. If the process has so far advanced that rolls of omentum, or agglu- 
tinated masses of mesentery and intestine have formed, palpation over the 
abdomen and the finger in the rectum will readily reveal the presence of 
these tumors. The abdomen may then appear flat or gas-distended, and 
Thomayer's sign of dullness on percussion on the left side of the abdomen, 
with a tympanitic note on the right side, may be obtained; in this latter 
condition fluid is rarely made out before operation, and only small quantities 
are seen on opening the abdomen. 

In the early stages of the ascitic form we should if possible exclude 
circulator}?-, renal and hepatic disturbances, and abdominal growths. The 
general nutrition may still be fairly good. The fluid readily gravitates to 
the dependent section on change of position. Corroborative evidence may 
be obtained by finding Marfan^s symptom, that is, the presence of pleuritic 
friction rales at the base of the lungs, sometimes associated with small 
exudations into the pleura. Pain is rarely obtained on palpation, but 
indefinite colicky pains are complained of. If, coupled with the above 
symptoms, the skin is harsh and dry, and subcuticular nodules are present 
over the abdomen, the diagnosis, now fairly certain, should be confirmed by 
laboratory and tuberculin tests. The frequent use of the thermometer 
showing predominating small evening rises and the presence of large num- 
bers of lymphocytes always tend in favor of a tuberculous process. In a 
tuberculous peritonitis the mononuclear leukocytes are generally increased. 
Cytological study of the tapped ascitic fluid may also assist in confirming 
the diagnosis. The diagnosis in the first form is not always certain without 
further tests, and even the last-described variety may cause confusion. 

If a chronic peritonitis of the tuberculous variety is suspected, a very 
thorough examination of the entire body should be made for possible tuber- 
culous disease in other organs not only to confirm the diagnosis, but to 
determine what shall be the character of the treatment and the prognosis. 
For if the lungs are involved and the spleen and liver are enlarged, general 
miliary tuberculosis is in all probability present, and the patient is beyond 
the hope of recovery. Whether or not the peritoneal process is tuberculous 
may be confirmed either by the skin-inoculation test of Von Pirquet, by the 
Moro reaction (i.e., a 50 per cent, tuberculin ointment) or by the Calmette 
test; but this is not recommended if there is any possibility of corneal 
involvement. The catheterized urine may be centrifuged for the presence 
of tubercle bacilli, or inoculation tests can be made with guinea-pigs. 

Treatment. — The trend of opinion, buoyed up by some successful 



TUBERCULOSIS. 



319 



results in recent years, tends toward operation in all cases of tuberculous 
peritonitis, especially as the operation is comparatively simple and not 
dangerous to life. If more regard had been paid to the general examination 
and only selected cases operated upon, the statistics would have been stead- 
ily in favor of operation. The ascitic form of localized tuberculous peri- 
tonitis does well under laparotomy, the plastic form rarely does well ; fistula? 
are apt to form, and the lungs frequently show early involvement following 
the laparotomy. Again, if the diagnosis can be made early in the ascitic 




Fig. 91. — Tuberculous dactylitis. 



form non-operative interference may be counseled provided the circum- 
stances are such that all the advantages accruing from life at the seashore, 
rest and nutritious food are possible. Otherwise the child should be 
watched, and if the exudate is on the increase operation should be recom- 
mended. A life in the fresh air 3 confinement to bed while an active process 
is going on, food high in proteids and fats, with the addition of cod-liver oil 
and the syrup of the iodid of iron, are indicated after laparotomy, and for 
the inoperable cases. 



320 



DISEASES OF CHILDREN. 



Bone and Joint Tuberculosis. 

(Caries of Bone.) 

This affection is the result of the invasion of tubercle bacilli in the 
spongy portion of the bone. Usually beginning as a single focus, it spreads 
and often involves the whole epiphysis. Tubercles are formed which later 
may degenerate, forming many necrotic areas which may merge to form a 
caseating area. Granulation tissue is 
found at the periphery. In some in- 
stances a sequestrum forms or an abscess 
results. The joints are infected through 
the cartilage, and the disease rapidly 
spreads to the synovial membrane, 
where ulcerations form. When the car- 
tilage becomes detached, destruction 
begins in the bare bone. In this way 
deformities so common in and about 
the joints are produced. 

Etiology. — The infectious dis- 
eases, especially measles and scarlet 
fever, are probably more often the 
direct cause of tuberculous joint dis- 
eases than traumatism. Any devital- 
izing disease, however, must be consid- 
ered as a factor. The affection is ex- 
tremely rare in infants. After the 
third year it is distinctly a disease of 
childhood. 

Tuberculosis of the Vertebrae. 

(Potfs Disease; Caries of the Spine; Spondylitis.) 

This affection is the result of a tuberculous osteitis in the spongy por- 
tion of the bodies of the vertebra. 

It is extremely common in early childhood, and, according to Taylor, 
more than half the cases occur under six years of age. The dorsal region is 
most often affected ; the cervical less commonly. 

Diagnosis. — If careful physical examinations were oftener made with 
the child completely undressed, the diagnosis would more frequently be 
reached in the early stages. The abnormalities which should attract atten- 
tion are the rigidity of the spine, and in walking a deficient mobility of the 




Fig. 92. — Torticollis, due to cer- 
vical Pott's disease. (Bradford 
and Lovett.) 



TUBERCULOSIS. 



321 



spinal column when tested by the examiner. Deformities due to necrosis 
of the bone will be apparent on observation, often forming the familiar 
humpback. The peculiar attitude and gait assumed may attract attention, 
even before the child is undressed. 

In cervical Pott's disease, wry- 
neck may be the first symptom com- 
plained of. The differential diagnosis 
from other forms of torticollis is some- 
times very difficult. The slower onset, 
the posture, and the general muscular 
fixation serve to distinguish it. 

Dorsal Pott's disease is distin- 
guished by the erect military gait, the 
lateral deviation, with a bony deformity, 
which can be palpated and usually 
easily seen. 

Lumbar Pott's disease. — Here 
the attitude of lordosis should attract 
attention, especially if accompanied 
with deviation to one side, and a care- 
ful abnormal gait. Hyperextention of 
the leg in the prone position elicits the 
sign of psoas contraction. 

Paralysis. — This may occur at 
any time in tuberculous spinal disease, 
although as a rule it occurs as one of 
the later symptoms. 

The patellar reflexes are increased, 
ankle clonus may be present, and the 
pain, if absent before, is now present 
or increased in severity. 
A rachitic spixe is often mistaken for Pott's disease. The curve, 
however, is rounded and the spine is supple. If the child is raised with 
the hands of the examiner in the axilla the curvature tends to disappear. 
Other bony changes or the symptoms of rickets may be present. The de- 
formity in Pott's disease does not disappear when the child is raised or is 
in the prone position. 

Treatment. — This is mainly orthopedic and involves the use of appa- 
ratus to promote spinal rest (Pig. 95) and the correction and prevention 
21 




Fig. 03. — Dorsal Pott's disease. 



322 DISEASES OF CHILDREN. 

of deformities. The medical treatment encompasses dietetics and hygienic 
management. The Albee bone graft offers a more rapid cure with less 
deformity. 




Fig. 94. — Lumbar Pott's disease. 

Tuberculous Disease of the Hip. 

(Hip-joint Disease; Morbus Coxce; Coxalgia.) 

This affection is due to a tuberculous osteitis of the head of the femur, 
of the acetabulum, or both. The disease usually begins gradually, the par- 



TUBERCULOSIS. 



323 



ents first noticing a limp. Night cries occur, but pain is a very variable 
symptom. The attitude assumed is one with a little flexion of the knee of 
the affected side and a slight tilting of the pelvis. In later stages of the dis- 
ease much can be learned by testing 
the child for freedom of motion, pick- 
ing up objects, mensuration, pain and 
swelling. The classical symptoms upon 
which a diagnosis can be based with 
certainty are limit of motion, muscular 
spasm, pain, swelling, attitude, short- 
ening and atrophy of muscle. The 
X-rays and the tuberculin tests may be 
required in difficult cases. 

Treatment. — Immobilization and 
protection of the joint by casts, trac- 
tion, and later, braces ; a life in the open 
air and good food do much to assist 
the orthopedic measures. Osteotomy 
and excisions are performed only in 
desperate cases. 

Tuberculous Disease of the Knee. 

(Gonitis Tuberculosa; White Swelling.) 

The epiphyses are nearly always 
primarily involved. It is most com- 
monly observed in children, and, after 
the spine and hip involvement, it occurs 
most frequently. 

The diagnosis is usually quite 
readily made, as the knee-joint easily 
lends itself to examination. Swelling, 

with lameness which may be intermittent, are the first diagnostic symptoms. 
Stiffness and pain follow. Muscular spasm on passive motion may be 
observed. The knee may be held in a position of flexion. Infectious 
synovitis is distinguished by the more rapid onset, temperature, and signs 
of localized inflammation. 

Chronic synovitis is very slow in its course and is not accompanied by 
much lameness or pain. Sometimes crepitus may be obtained. Eventu- 
ally a true tumor albus may result. The X-rays, tuberculin, and inocula- 
tion tests may be made if necessary. 




Fig. 95.— Infant with Pott's disease 
on a Bradford frame. 



324 DISEASES OF CHILDREN. 

Treatment. — The medical treatment does not differ from that of 
tuberculosis elsewhere. The joint should be encased in a splint which will 
prevent joint motion of the knee and foot. 

Treatment of Tuberculosis in General. 

Prophylactic. — There are but few diseases in which prophylaxis can 
accomplish so much for the child as in tuberculosis. Upon the physician 
and health officer the duty devolves, and it begins even before conception. 
It is largely a problem of sociology and preventative medicine. 

Laws which have lately been passed in many States prohibiting the sale 
of tuberculous milk and meat, tenement-house inspection, health-board 
notification, and the educational exhibits will all tend to decrease the 
spread of this disease. Tuberculous mothers should not nurse their children 
because of danger in the close contact. 

Milk for infant feeding should be obtained from tuberculin tested 
cows, or should have the stamp of approval of a medical commission as being 
"certified/' Where this is not possible the milk should be pasteurized. 

The children of tuberculous parents should be brought up, if possible, 
in the country and early trained to live an outdoor life. Such defects as 
adenoids or carious teeth should be removed. They should be especially 
guarded from measles and whooping-cough. 

School houses should be so arranged that proper ventilation can be 
obtained in rooms with ample air space and sunlight. Teachers, who as a 
class are particularly susceptible to the disease, should be frequently exam- 
ined. 

Knopf has formulated the following valuable set of rules for school 
children : 

Do not spit except in a spittoon or a piece of cloth or a handkerchief 
used for that purpose alone. On your return home, have the cloth burned 
by your mother or the handkerchief put in water until ready for the wash. 

Never spit on a slate, floor, sidewalk, or playground. 

Do not put your fingers into your mouth. 

Do not pick your nose or wipe it on your hand or sleeve. 

Do not wet your fingers in your mouth when turning the leaves of 
books. 

Do not put pencils into your mouth or wet them with your lips. 

Do not hold money in your mouth. 

Do not put pins in your mouth. 

Do not put anything into your mouth except food and drink. 



TUBERCULOSIS. 325 

Do not swap apple cores, candy, chewing-gum, half -eaten food, whistles, 
bean-blowers, or anything that is put into the mouth. 

Peel or wash your fruit before eating it. 

Never cough or sneeze in a person's face. Turn your face to one side 
and hold a handkerchief before your mouth. 

General. — Reports from the sanatoria would indicate that the child 
over four years of age afflicted with tuberculosis in the incipient stage has a 
better prognosis than the young adult. Graduated heliotherapy is a form 
of treatment that is particularly suitable to the child. This is borne out 
by our own dispensary cases, which have had but indifferent opportunities, 
and still have shown gratifying results. 

The diet for these children should consist principally of milk, eggs, 
and fats; such as butter, cream, olive or cod-liver oil, and meat for older 
children. The syrup of the iodid of iron should be given. If the appetite 
fails a change from inland to seashore or vice versa may be proposed, or if 
this is not feasible the tincture of nux vomica with the compound tincture 
of cardamon can be given before meals. Medication directed to the disease 
itself is useless and often harmful. In hopeless cases the symptoms are 
alleviated as they arise. 

The tuberculin treatment is again being tried in children's hospitals 
and with more success. Good results are obtained in localized conditions, 
and some cases having pulmonary involvement have been benefited. The 
former unsatisfactory results are attributable to our meager knowledge of 
its action, and probably to overdosage, which seemed to produce harmful 
results. 

Children in whom the disease seems to be arrested, as shown by 
absence of temperature and increase in weight, are especially suitable for 
the tuberculin treatment. The injection in these quantities may be given 
twice a week until a tolerance is reached, when the dosage may be slowly 
increased by 0.1 mg., depending upon the effect produced. 1/12,000 to 
1/8000 mg. of T. R. tuberculin is given to a child one year old. 1/4000 
mg. for a child five years old. 1/3000 mg. for a child ten to twelve years 
old. Its effect should be watched, and a dose given every two weeks. The 
weight and general progress of the child must act as guides. 



SECTION VII. 
DISEASES OF THE RESPIRATORY TRACT. 



CHAPTER XXIII. 
DISEASES OF THE UPPER RESPIRATORY TRACT. 

Acute Rhinitis. 

This is quite commonly seen in infants and children, and is due to 
bacterial infection as a result of a temporary or prolonged lowered resist- 
ance. This is made possible by keeping the child in superheated apart- 
ments, sudden changes of temperature, or exposing it to direct infection 
from a member of the household. There is at first a constant serous and 
later mucopurulent discharge from the nares, with irritability, restlessness 
in sleep, loss of appetite, and a slight temperature. 

In infancy the symptoms are of greater import than in childhood, as 
it may seriously interfere with nursing and thus add to the lowered resist- 
ance through malnutrition. Sleep is broken, feeding rules are interfered 
with and disturbances of the gastrointestinal tract may result. Older chil- 
dren complain of fullness in the head and chilliness. Children who have 
frequent attacks of rhinitis are ofttimes sufferers from adenoids. 

Treatment. — While rhinitis is a self -limited disease, lasting from 
one to two weeks, it should not be left untreated. The infection may spread 
to the lower respiratory tract and end disastrously. If possible, remove 
the indirect cause, as, for example, badly heated and unventilated rooms. 
The child is best confined to one room, especially if there are other children. 
Locally liquid albolin with camphor gr. i to the ounce may be instilled into 
the nose. A solution of adrenalin chlorid 1 to 5000 in infants and 1 to 
1000 in older children gives temporary relief before suckling and at bed- 
time. Morse found it necessary to introduce a small rubber catheter into 
each nostril in a serious case to enable it to breathe. Small supportive 
doses of strychnia 1/240 t.i.d. are sometimes necessary to assist the child in 
ridding itself of the infection. The ears should be examined daily, as an 
otitis is very likely to supervene by extension. 

32G 



DISEASES OF THE UPPER RESPIRATORY TRACT. 327 

Epistaxis. 

Bleeding from the nose is not often seen in infants, although not 
uncommon in children; when it occurs in infants it is usually a result of 
adenoids, syphilitic rhinitis, or an ulceration of the nasal mucous mem- 
brane, commonly found on the anterior and inferior portion of the septum. 
Children are liable to nose-bleed because of their tendency to acquire 
turgidity of the nasal mucous membrane. Traumatism, adenoids, foreign 
bodies, and purulent rhinitis are among the more common causative factors, 
while a nose-bleed is also seen in the course of many of the infectious and 
blood diseases of early life. A history of frequent epistaxis should lead one 
to examine for adenoids, ulcers, or cardiac disease. 

Treatment. — Keep the child in the upright position and apply pres- 
sure with the fingers against the septum, meanwhile having an ice applica- 
tion held over the cervical spine. If bleeding still persists pack the nose 
with cotton which has been dipped in a 1/2000 adrenalin solution. 

As soon as feasible, make a careful examination for the underlying 
cause. If an ulcer, cleanse and apply a 20 per cent, solution of nitrate of 
silver. If adenoids are present, they must be removed; this is especially 
true in infants who have frequent nose-bleed. "Warning should be given 
the attendant as to the significance of swallowed blood from a nose-bleed, 
which may occasion unnecessary alarm when vomited. 

Foreign Bodies in the Nose. 

In children, usually between two and five years, it is not uncommon to 
find that they have placed various objects in their noses. These may cause 
immediate symptoms of annoyance or distress or, becoming lodged, cause a 
unilateral nasal discharge that is persistent. Closer examination shows a 
partial or total occlusion of that side of the nares, a mucopurulent discharge, 
occasionally blood-tinged, and. with some objects, an odor of putrefaction. 
AVe have removed peas, pearl buttons, shoe-buttons, paper, and a kernel of 
corn. 

Treatment. — Place the child in a good light and use a small nasal 
speculum. The object if in situ for some time may be covered by mucous 
membrane or altered in appearance so as to be unrecognizable. If there is 
still doubt, a probe slightly bent can be inserted and the obstruction recog- 
nized ; wipe out the discharge and with a nasal forceps, snare, or hook 
remove it, If the object has been recently inserted and is not high up, 
causing the child to sneeze by tickling the opposite side has succeeded easily 
in effecting its dislodgement. The rhinitis induced clears up rapidly after 
the offending material is removed. 



328 



DISEASES OF CHILDREN. 



Examination of the Throat in Infants. 

A careful inspection of the throat should be made as part of the rou- 
tine examination of the sick infant. Many attacks of fever and illness in 
infants are due to inflammation of the throat, such attacks being not infre- 
quently attributed to some other cause. 
The principal reason for such a possible 
error lies in the difficulty in getting a satis- 
factory view of the fauces. This is especially 
true in very young infants. The tongue is 
high and the soft palate and pillars of the 
fauces low down, so that it is extremely diffi- 
cult to get a clear view of the parts. Unless 
a satisfactory view is obtained at the first 
attempt it becomes increasingly difficult, if 
not impossible, to see clearly at all. The 
opening is so small that a little mucus pro- 
duced by the irritation of a second or third 
examination completely obstructs the view. 
In addition to this some milk is apt to be 
regurgitated from the stomach, and then it 
is absolutely impossible to see the real con- 
dition of the mucous membrane. 

Most of the tongue depressors in use are 
not only too large, but do not have the 
proper slant for the infant's tongue. As a 
result, the back of the tongue, not being 
properly held, arches up and obstructs the 
view of the fauces. The depressor here pre- 
sented is small enough for the youngest in- 
fant's mouth, and is intended to curve over 
the tongue to the base of the epiglottis. It 
can likewise be used in older subjects. By 
exercising a little pressure downward and 
forward the parts will come into clear view. 
Of course the infant should be properly held 
and placed before a good light (Fig. 98). 
When everything is in readiness the left hand 
is used to steady the head while the right 
hand manipulates the depressor. These details will naturally suggest 
themselves to the careful physician, but are often overlooked, with the 
result of unduly fretting the infant and failing in the examination. 




Fig. 96. — Chapin's tongue 
depressor ( straight). 



DISEASES OF THE UPPER RESPIRATORY TRACT. 



329 



Pharyngitis and Tonsillitis in Infants. — In infants, tonsillitis, as 
distinct from pharyngitis, is rare. The whole mucous membrane of the 
pharynx and tonsils is involved in the inflammation. The tonsils may be 
somewhat enlarged and are covered with very fine pin-head points of a 
whitish exudation. These points can be recognized only when the fauces 
are well exposed in a good light. In rare instances the uvula is swollen 




Fig. 97. — Chapin's tongue depressor (curved). 



and infiltrated. The secondary forms of pharyngitis seen in most infec- 
tive diseases will not be here considered. The primary form is apt to be 
overlooked from the absence of symptoms referable to the throat, and the 
inability of the infant to call attention to the affected part The swelling 
of the lymph-glands of the neck, so often noted in diphtheria and scarla- 
tina, is not usually present in primary pharyngitis. The two most com- 
mon predisposing causes of primary throat inflammation in infants are : 
(1) disordered stomach and (2) exposure to cold. The frequent mistakes 
in the feeding of infants, especially overfeeding, produce an acid fermenta- 
tion in the stomach. By direct continuity the mucous membrane of the 
pharynx and mouth may become irritated and inflamed. When the latter 
happens the temperature keeps up instead of subsiding when the stomach 
is relieved of its contents by vomiting or by their passage into the bowel. 
Exposure to cold is likewise a common predisposing cause. Many infants, 
especially among the poor, are too warmly clad, especially about the neck 
and chest. As a result the skin is constantly moist. Such infants live and 
sleep in overheated rooms. In these cases an ordinary exposure to cold 
will induce throat inflammation through bacterial invasion. 



330 



DISEASES OF CHILDREN. 



It will be noticed that the causes here given are mentioned as predis- 
posing. Most, if not all, forms of tonsillar and pharyngeal inflammation 
are due to the presence of pathogenic organisms. In health and under good 
hygienic conditions the mucous membrane of the throat may not be un- 
favorably affected by organisms, but under depressing conditions, particu- 
larly when the digestive tract is in an irritated condition, the throats of 
infants are vulnerable. It is quite possible that many impurities may like- 
wise find their way to the mouth and throat by means of dirty fingers or 




Fig. 98. — Method for examination of the throat. 



objects which are given to infants as toys and which quickly find their way 
to the mouth. 

Treatment. — The treatment consists in removing the cause, whether 
it be a deranged stomach, defective action of the skin, or faulty hygienic 
surroundings. The recurrence of attacks of pharyngitis in infants is the 
most common cause of postnasal rhinitis in children. The repeated irrita- 
tion induced by these attacks causes hypertrophy of the adenoid tissue at 
the vault of the pharynx, which is the invariable accompaniment of rhinitis 
in the later years of childhood. 

The immediate treatment consists in opening the bowels with a mild 



DISEASES OF THE UPPER RESPIRATORY TRACT. 331 

laxative dose of castor oil or calomel, followed by small and frequent doses 
of tincture of aconite, one-quarter to one-half a drop every two hours. If 
restlessness is a prominent symptom, a grain of phenacetin may. be given 
every three hours for a few doses. As the acute form of the disease is self- 
limited, it is not well to give drugs very freely, especially those that tend 
to upset the digestion. The importance of recognizing the condition con- 
sists in taking steps to prevent its recurrence. 

Acute Pharyngitis. 

Definition. — An acute inflammation of the pharynx and neighboring struc- 
tures. 

Etiology. — Sudden exposure to inclement weather which is dust and germ 
laden predisposes to the affection. It is present in the early stages of many of 
the acute infectious diseases and may accompany gastric disorders. Exposure to 
chemical irritants in the form of vapors which produce a pharyngitis. Children 
with obstructions in the respiratory tract, especially adenoid growths, are liable 
to repeated attacks. 

Symptomatology. — Locally there is seen a reddened congested pharynx with 
the uvula and tonsils sharing in the inflammatory process. The larynx and naso- 
pharynx may also be involved. There may be a rise of pulse and temperature, 
but this is rarely high. The child complains of sore throat and difficulty in swal- 
lowing. Under appropriate treatment there is a rapid subsidence of symptoms. 

Diagnosis. — With high temperature and vomiting scarlet fever must be kept 
in mind. Measles will show the presence of Koplik's spots, while a diphtheritic 
process will show a beginning membrane and give a positive culture. 

Treatment. — Prophylactic treatment resolves itself into the removal of any 
obstructions to proper breathing and the maintenance of proper resistance against 
infections. 

Locally. — Cold compresses applied every half-hour. Mild antiseptic gargles 
for older children, such as the Liq., antisepticus alkalinus N.F. or Dobell's solu- 
tion, one part to eight of water will suffice if used every two hours. 

Constitutional. — An initial laxative, such as the citrate of magnesia or calo- 
mel, should be prescribed. If there is high temperature and much discomfort 
phenacetin with salol. 2 grains of the former to 1^ grains of the latter, for a five- 
year-old child, will be efficacious. The diet should consist of cool demulcent 
preparations, such as oatmeal or barley gruel, junket or ice-cream. 

Acute Follicular Tonsillitis. 
( A cute A mygdalitis. ) 

This is a self-limited disease of short duration, usually bilateral, with 
constitutional symptoms and a marked local infective process involving the 
tonsillar crypts and the entire glandular structure. 

Etiology. — Children with rheumatic tendency or of a lymphatic type 
are prone to acute attacks ; those with chronically enlarged tonsils being 
particularly susceptible. In these latter cases, slight exposure to colrl often 
brings on an attack. One infection predisposes to a second, presumably 
because of the presence of bacteria in the crypts or their accessibility to the 
tonsil through the mouth and nose. 



332 DISEASES OF CHILDREN. 

Symptomatology. — The onset of tonsillitis is sudden; a chill or 
chilly sensations often being the first evidence. This may be followed by 
marked prostration, malaise, and vomiting. The temperature is high, fre- 
quently rising to 104° or 105° F. At first the tonsils and soft palate are 
reddened and swollen, and in a few hours cream-colored isolated spots appear 
on the tonsil plugging the mouths of the crypts. These spots are about the 
size of a pin-head, though at times they coalesce, forming a pseudomem- 
brane which can be easily wiped off with a swab without producing a de- 
nuded or bleeding area. The membrane does not spread to the soft palate 
nor to the pillars of the pharynx. 

Frequently the glands at the angle of the jaw are enlarged and these, 
together with the inflamed tonsils, produce considerable discomfort and 
pain on swallowing. A routine examination of the throat in all cases will 
often disclose a tonsillitis which has produced no subjective symptoms. 

Course and Prognosis. — The inflammatory condition is active for 
at least three or four days even under treatment, but because of the consti- 
tutional symptoms convalescence may be slow; ten days usually elapsing 
during this stage. The prognosis is good if the patient is well cared for, 
though the danger of endocarditis and the possibility of peritonsillar 
abscess must not be forgotten. 

Differential Diagnosis. — ■ At the onset, tonsilitis may be confounded 
with malaria, pneumonia, scarlet fever, or influenza. A careful history and 
blood examination will usually eliminate the first ; a careful physical exam- 
ination and absence of disturbed pulse-respiration ratio would differentiate 
it from pneumonia, while further observation for twenty-four hours will 
render the diagnosis more certain on account of the more characteristic 
appearance of the tonsils. From diphtheria, the absence of Klebs-Loeffler 
bacilli, the sudden onset and initial chill, the position and character of the 
local lesion, the high temperature and the absence of a history of exposure 
to diphtheria infection point strongly to the diagnosis of follicular tonsil- 
litis. (See Plate XI.) 

In ulceromembranous tonsillitis, the constitutional symptoms are 
much milder ; the pain in the throat more severe, and enlargement of lymph- 
glands more marked. The local lesion is usually one-sided, the affected 
tonsil being covered with a dirty yellowish exudate closely resembling the 
membrane of diphtheria. 

Treatment. — Eest in bed is imperative on account of the great danger 
of endocarditis. Depletion by calomel gr. 1/10 every half-hour for ten 
doses will reduce the intoxication. Hot fomentations or cold compresses to 
the throat will give relief from pain. Alcohol sponge baths when the tern- 



DISEASES OF THE UPPER RESPIRATORY TRACT. 333 

perature is high will add materially to the comfort of the patient. During 
the first twelve to twenty-four hours the following may be given to a child 
two years old : 

E> Phenacetini gr. | 

Salol gr. j 

Oleosacchari anisi, q.s. 

M. Ft. pulv No. j 

Misce et signa. — One every three hours. 

For young children who have not learned to gargle, a very efficient local 
application to be used on a swab every two or three hours is the following : 

B2 Tincturse iodini tti iv 

Argyrol sol. 50% gtt. iij 

Aquae q.s. ad. 3ss 

Misce et signa. — Swab on tonsils every two to three hours. 

Older children may gargle with the Liq. antiseptic, alkalinus (N. F.) 
or any of the equally efficient mild antiseptic solutions. 

Ulceromembranous Tonsillitis. 
{Vincent's Angina.) 

Clinically, this affection closely resembles a mild diphtheria; bacterio- 
logically, the findings show the presence of an elongated fusiform bacillus 
and long wavy spirilli. The general symptoms are mild or absent except 
for the pain in the throat, which is severe. 

The lesion is a superficial ulcer on the tonsil the size of a dime, usually 
unilateral in location, of a dirty yellow color, and exhibiting no great ten- 
dency to spread. If the ulceration is deep, upon an attempt to pull off the 
membrane the underlying surface bleeds slightly. The cervical glands are 
enlarged and the muscles along the side of the neck are stiff and tender. 
The pulse and temperature are moderately increased, the latter closely re- 
sembling the temperature in diphtheria. 

As a rule, the breath is foul and there is much drooling. Hot anti- 
septic gargles and mildly astringent applications (see p. 332) locally, 
combined with hot or cold external applications, are very efficient measures 
of relief. 

The disease runs a more prolonged course than a follicular tonsillitis. 
A smear and culture should be made in all suspicious cases for purposes of 
differentiation. 

Streptococcus Sore Throat (Streptococcic Angina). 

(Formerly considered as: Membranous Tonsillitis; Croupous Tonsillitis; 

Pseudo-diph th eria. ) 
This disease may occur as a secondary condition in various infectious 
diseases, especially scarlatina, or as a primary inflammation, when it may 
prove to be a form of milk poisoning. 



334 DISEASES OF CHILDREN. 

Etiology. — The inflammation is caused by streptococci of varying 
degrees of virulence, sometimes associated with staphylococci. Children 
with lowered vitality from any cause, and especially institutional children, 
may harbor streptococci in their throats. The same condition may occa- 
sionally be found in healthy children, when cold or inclement weather may 
cause the inception of the disease. In recent years, several epidemics have 
been traced to infected milk. It has been found that a combination of 
mastitis in cows with sore throat in the milkers has been followed by an 
epidemic in the region supplied by such a farm. Conversely, it has been 
proven by Capps and others that hemolytic streptococci of human origin 
may cause mastitis lasting for several weeks in cows, which time roughly 
corresponds to the relation of milk-borne epidemics. 

Symptomatology. — Two forms of the disease may be recognized, the 
mild and severe. The onset is rapid and well marked with vomiting, chilli- 
ness, headache and grippy pains. The temperature is usually high — from 
103° to 105° F. — which in the milder cases subsides by the third or fourth 
day. The condition of the throat is variable. At first there is a diffused 
redness involving pharynx and tonsils, resembling a scarlatina throat, but 
this is soon followed by patches of exudate in the form of a pseudomem- 
brane. These patches may be limited to the tonsils, but in severe cases they 
may cover the pharynx and extend to the soft palate, the nose and rarely the 
larynx. Morphologically the membrane is like that of diphtheria, but con- 
tains streptococci and no diphtheria bacilli. In severe cases it assumes a 
yellowish or dirty-green appearance. The lymph nodes of the neck become 
swollen and sore, and, in severe cases, may undergo suppuration. Abscesses 
in the peritonsillar region may also occur. There is always prostration, 
but, in the milder cases, the symptoms usually subside in four or five days 
and the patient goes on to complete recovery. In the more serioas type 
there is evidence of an extensive streptococcus infection. This general 
sepsis shows itself by great prostration, irregular and high temperature, and 
occasionally delirium or stupor. Nephritis usually supervenes, and pleu- 
risy, bronchopneumonia and even erysipelas may occur and prove to be the 
terminal condition. 

Diagnosis and Prognosis. — The only positive method of differentia- 
tion from diphtheria is by culture. The membranes seen during the early 
course of scarlatina are usually caused by streptococci. The prognosis is 
good in all but the severest types of the disease. In the latter the mortality 
may run as high as from 10 to 20 per cent. 

Treatment. — In young children antitoxin should be given at the start 
if there is any doubt as to the nature of the disease. Benefit will be derived 



DISEASES OE THE UPPER RESPIRATORY TRACT. 335 

from irrigation of the throat, and nose if affected, with hot normal salt 
solution as in diphtheria. Ice bags to the neck may be applied when this 
part is swollen or painful. Stimulation by strychnin, camphor or caffein 
may be required in the severe cases, and soft nourishment, frequently admin-, 
istered, will serve to keep up the strength. When occurring as an epidemic 
the milk supply of the affected area must be diligently investigated by the 
health authorities, and any suspected farm quarantined and its milk supply 
cut off. This was successfully done in the epidemics at Boston, Chicago 
and Baltimore. 

Chronic Tonsillar Hypertrophy. 

A condition of chronic enlargement of the tonsils is seen in many 
children giving a history of repeated attacks of tonsillitis, or as a result of 
the infectious diseases. Adenoid vegetations and hypertrophied tonsils are 
associated in many cases. 

Symptomatology. — There is impaired phonation and the train of 
symptoms which are associated with adenoids, the distress being especially 
produced at night during sleep. Restlessness and snoring are marked. 
Anemia and anorexia result. 

Treatment. — Chronic enlargements should be removed. Cocain as an 
anesthetic should not be used. If adenoids are present remove the tonsils 
first. An anesthetic is necessary, and the child should be prepared as for 
the adenoid operation. 

The head may be slightly raised and the assistant should gently press 
the tonsils from the outside, toward the middle line. The results obtained 
seem to warrant complete excision with special instruments. Complete enu- 
cleation is desirable, produces less traumatism, and better after-effects. 

Adenoids. 

(Hypertrophy of the Pharyngeal Tonsil.) 
This term is applied to a hypertrophy of the Lymphoid tissue normally 
found in the pharyngeal vault. 

Etiology. — ■ Adenoids are found at all ages and are far from infre- 
quent in infants. Children who have lived in a poor hygienic environment 
or whose parents have chronic diseases seem to inherit a tendency to ade- 
noids. They are usually associated with enlargement of the faucial tonsils. 
Rickets and the condition known as the lymphatic diathesis predispose to 
adenoid vegetations. Kerley believes that the pernicious use of the so-called 
comforter with the constant Bucking is directly productive of adenoids. 

Symptomatology in Infants. — The symptoms differ considerably in 



336 



DISEASES OF CHILDREN. 



infants, and therefore will be described separately. The babe may be 
brought because it cannot suckle without frequently stopping to breathe 
through its mouth. Sleep is broken and the infant cries and almost chokes 
when it drops into a deep sleep. A persistent rhinitis is commonly observed, 
and sniffling may be the most prominent symptom. The expression is not 
changed as in older children. 




Fig. 99. — Typical adenoid face. 



In Children. — In early cases the child is brought for examination 
because of frequent " colds in the head " associated with troubled sleep and 
snoring. In more aggravated conditions, mouth-breathing, snoring at 
night with tossing, restless sleep, and occasional night terrors should lead 
to a careful nasopharyngeal examination. In typical cases, the vacant 
expression, fish-like face, and open mouth, often with a high arched palate, 
are readily noted. The face in these mouth-breathers has often been visibly 
deformed (Fig. 99). The following characteristics make the diagnosis sim- 
ple: partly pursed mouth, protruding lower jaw; narrowed long face; 
Y-shaped palate ; enlarged tonsils ; narrow alse nasi ; dull eyes ; pale mucous 
membranes; narrowed chest, sometimes otitis and evidences of general mal- 
nutrition. These children have a nasal twang to the voice and are poor 
scholars. They tire easily, do not eat well, and may suffer from incontinence 
of urine. There may be partial deafness from obstruction of the Eustachian 
tube. If a granular pharyngitis with plugs of mucus hanging from the 



DISEASES OE THE UPPER RESPIRATORY TRACT. 



337 



posterior nares is observed, adenoids are usually present. A useful test 
generally indicating nasal obstruction due to adenoids is to request the 
child to repeat the words " Clapham Common " which he cannot enunciate 
without a nasal twang. 

Examination. — In infants it is a difficult procedure, but may be 
occasionally accomplished with care and patience; the little ringer must be 
used for exploration as the space is so small. In older children the ringer 
properly protected should be passed into the nasopharyngeal space and the 
amount and character of the adenoid tissue appreciated. Soft pendulous 
masses or firm growths may be felt and, if the vault is found to be occluded 
with hypertrophied tissue, operative interference should be resorted to. 




Fig. 100. — Method of palpating for adenoids. 

Treatment in Infants. — If the symptoms of obstruction are such as 
to interfere with the infant's nutrition, the adenoids should be carefully 
and completely removed by an expert. Palliative measures are ofttimes 
successful in le>s aggravated cases, and we have found the instillation of a 
mixture such as the following to be of benefit: 

ly Camphora? er i 

Menthol ...'...'...'.'.'.'. Ir! j 

Resorcini | r ' jj 

Benzoinol §j ' 

Misce et signa. — Five drops every three hours into the nares with a medi- 
cine dropper. 

B Adrenalini inhalantis 3ss 

Liquid] albolini q. s. a d §ss 

Misee et signa. — A few drops in nares night and morning. 

22 



338 DISEASES OF CHILDREN. 

In Older Children. — Palliative measures here are useless. The ope- 
ration should be performed under a general anesthetic if there are no 
contraindications, such as bronchitis, acute tonsillitis, etc. The adenoids, 
and if present, the enlarged tonsils are removed at the same time. The 
after-treatment is to break up the habit of mouth-breathing by careful 
instructions in proper breathing and corrective exercises. (See page 83.) 

Peritonsillar Abscess. 

(Quinsy.) 

A retropharyngeal abscess is more common in infancy than peritonsillar 
abscess. Older children, however, have abscess formation in the peritonsillar 
tissue, accompanied by fever, chilliness and difficult swallowing. The mouth is 
opened with difficulty and the tonsil on one side is seen to bulge forward. The 
finger elicits fluctuation when the condition is at its height. 

Treatment. — In the early stages calomel or effervescent citrate of magnesia 
may be given for the bowels. Salol and phenacetin, one and a half grains of 
each, may be given every three hours for a five-year-old child. Cold milk sucked 
through a tube is agreeable and keeps up nutrition. Incise with a guarded 
scalpel, and drain as soon as a diagnosis of an abscess is made. A gargle and 
occasional digital pressure for evacuation of the pus made over the affected site 
serve to prevent reinfection. 

Retropharyngeal Abscess. 

This abscess is seen not rarely in infants and children below the age of two 
years. Ill-nourished children are more prone to it because of their lowered 
vitality, and infection takes place from the organisms commonly found in the 
mouth. 

Symptomatology. — The infant is usually brought for examination because of 
difficulty in breathing. In the early stages there is mainly an inspiratory dyspnea, 
but as the abscess grows larger difficulty is experienced both in inspiration and 
expiration. During sleep there is a persistent rattling snore and the child fre- 
quently awakes to change its position. The child refuses nourishment or takes it 
with great difficulty. The temperature is irregular and fluctuates from 100° to 
103° F. When the head is bent forward ; the dyspnea is increased. 

Inspection with a suitable tongue depressor will show a rounded reddened 
mass protruding almost from the center or on one side of the pharyngeal wall. 
The examining finger detects fluctuation. 

Treatment. — It is imperative that the abscess be opened and thoroughly 
drained. The child's head should be held well forward and then downward when 
the abscess has been opened to prevent aspiration of the pus. Strychnin and 
whiskey are usually indicated to combat the septic absorption. In a few of our 
septic cases it has been necessary to feed the child by gavage for a few days 
following the evacuation of the pus. 

Acute Laryngitis. 

(Spasmodic Croup; Spasmodic Laryngitis; False Croup; 

Catarrhal Croup.) 

Etiology. — This is usually due to bacterial infection made possible 

by sudden exposure to cold or wet. It is most commonly met with from 

the second to the fifth vear of life and is apt to recur. Laryngitis occasion- 



DISEASES OF THE UPPER RESPIRATORY TRACT. 339 

ally anteeedes the eruption in measles. Children who have the spasmophilic 
tendency or who have nasopharyngeal obstructions are predisposed to the 
affection. 

Symptomatology. — The attacks usually come on -in the evening or 
at night. The child has appeared to be quite well during the day, and no 
symptoms have been observed except a slight rhinitis. Without warning 
a croupy harsh and brassy cough develops, accompanied by loud croupy 
breathing, heard with inspiration, expiration being quite noiseless. The 
patient is alarmed and the sleep is restless. The cough thoroughly alarms 
the mother and her fright is communicated to the child. In severe attacks 
the patient must sit up in bed to breathe; the suprasternal notch and 
diaphragmatic groove are retracted. After the attacks the child is exhausted 
and wet with perspiration. There may or may not be any temperature. 
The attacks even if uninfluenced by treatment, subside toward the morning 
hours, the harsh breathing ceases, and the child quietly rests. On the suc- 
ceeding day the patient is ready to play and the cough while present is not 
annoying. For several nights there will be a repetition of the dyspnea and 
croupy cough. 

Diagnosis. — Laryngeal diphtheria must be excluded. In diphtheria 
the breathing slowly becomes worse with no remissions. The constitutional 
symptoms are more marked and the inspiratory stridor may be present 
without the croupy cough. Seek safety in a culture, and if the weight of 
evidence leans toward diphtheria give antitoxin. 

Differential Diagnosis. 
Acute Laryngitis. Diphtheritic Laryngitis. 

Sudden onset. More gradual invasion. 

Dyspnea intense from start but evan- Dyspnea slowly but progressively worse. 

escent. Cough muffled and suppressed. 

Cough resonant and brassy (barking). Voice muffled and almost lost. 
Voice, usually normal. Inspiratory and expiratory stridor. In- 

spiratory stridor. spiratory more marked. 

Albumin rarely in urine. Albumin commonly found. 

No membrane seen. Membrane may be seen in pharynx and 

tonsils or coughed up. 

For differential diagnosis, from Laryngismus Stridulus, see p. 341. 

Retropharyngeal abscess will be differentiated by the increase in 
dyspnea when the head is dropped forward and by directly palpating a 
fluctuating mass. 

Prognosis. — Distinctly favorable, never fatal, but recurrences are 
common. 

Treatment. — Place the child in a warm, moist room. In mild cases 
an emetic dose of the wine of ipecac, half a dram every half-hour until 
vomiting ensues, may be sufficient to give relief. A warm mustard bath 



340 DISEASES OE CHILDREN. 

aids the result. An enema should be ordered if the bowels have not recently 
moved. In severer cases a croup tent (see page 341) should be made over 
the crib and a croup kettle started in which has been placed a dram or two 
of the compound tincture of benzoin. Emesis should be brought about as 
rapidly as possible. Antipyrin gr. 3 for a three-year-old child acts as an 
antispasmodic. If there is cyanosis and serious obstruction intubation may 
be necessary, however a smear and culture should be made to exclude 
diphtheria if possible, but it should be remembered that a negative culture 
does not mean that diphtheria is not present. 

The succeeding day should be spent quietly, a light diet given and the 
bowels kept open. If there are adenoids present, these should be removed 
at a later date. 

Edema of the Glottis. 
(Subm ucous laryngitis. ) 

Definition. — This is an infiltration of serum into the submucous layer of the 
glottis and the neighboring aryepiglottic folds. 

Etiology. — Serous infiltration may result from the irritative action of corro- 
sive drugs accidentally swallowed, from foreign bodies, or it may occur during 
the course of nephritis, syphilis, the infectious diseases, streptococcic inflamma- 
tion of the larynx or its neighboring structures by extension. It occasionally 
occurs in severe cardiac affections and with extensive edema of the lungs. 
Tumors, such as papillomata, have produced the condition. The angioneurotic 
type of edema of the glottis is extremely rare. 

Symptomatology. — The striking symptom is the inspiratory dyspnea which 
results. There is usually some stridor and a muffled voice. Pain and dysphagia 
are present when the edema is the result of a local inflammation resulting from 
trauma, hot steam, acids, etc. 

Inspection shows an engorged mucous membrane, swollen epiglottis, and nar- 
rowed rima glottidis. The folds of mucous membrane may overhang the glottis. 
The edema may be felt by the finger or seen by the laryngeal mirror. 

Course and Prognosis. — The course and prognosis are directly proportionate 
to the severity of the underlying disease or to the amount of trauma that has 
been caused. Unrelieved cases of edema of the glottis often terminate fatally. 
The milder types, due to the infectious diseases and kidney disease, improve with 
the amelioration of the primary cause. 

Treatment — In mild cases attention should be directed principally to the 
underlying disease. Diaphoretics and diuretics are distinctly helpful. Dover's 
powders will allay pain and restlessness until more heroic measures are taken. 
Scarification is occasionally successful in giving relief when performed by a spe- 
cialist. Tracheotomy is to be preferred to intubation in desperate cases when 
suffocation is imminent. 

Laryngismus Stridulus. 

Laryngismus stridulus is a neurotic disease of infancy, characterized by spas- 
modic attacks affecting the glottis and the neighboring laryngeal muscles. 

Etiology. Rachitic, spasmophilic infants and those with adenoids are espe- 
cially predisposed. Exposure to irritating gases or vapors, or badly ventilated 
apartments mav bring on an attack. 

Symptomatology.— This varies with the severity of the disease and with 
the particular spasm. In some cases the spasm is but momentary, ending with 
an inspiratory crow ; again it may recur every few moments with but slight 
inconvenience to the patient. In severe attacks the crowing inspiration is dis- 



DISEASES OF THE UPPER RESPIRATORY TRACT. 



341 



tinctly audible, the infant becomes spastic, and the efforts to breathe are 
marked. Lividity of the face and a gasping expression are observed. Carpopedal 
spasm and in some instances convulsions follow severe attacks. In the intervals 
the breathing may be quite free and unobstructed, with no constitutional symp- 
toms. Fatal cases are rare, but have been reported. 



Laryngismus Stridulus. 
Ill-nourished infants under two years. 
No pyrexia. 
No cough or rhinitis. 
Attacks momentary and recur often. 



Spasmodic Croup. 
(Acute Laryngitis.) 
Commonly from two to five years. 
Some pyrexia. 
Brassy cough and coryza. 
Attacks usually at night, last longer 
and have longer periods of remission. 




Fig. LOl— Croup tent. 



Treatment. — In the severe cases, emesis with wine of ipecac in half-dram 
doses every half-hour until vomiting ensues may be employed, with cold sponging 
of the face and chest. A cleansing enema in a badly-fed rickety infant is often 
effectual. The underlying cause must be removed or combated in the interval. 
Adenoids should be removed, and the infant placed on a properly proportioned 
diet. This alone is curative in certain babies fed on the proprietary foods. A 
quiet atmosphere and a well-regulated dietary will cure the majority of cases. 



342 DISEASES OF CHILDREN". 

Congenital Laryngeal Stridor. 
(Congenital Infantile Stridor. Thymic Asthma.) 

This congenital condition is rare and is often confused with laryngismus 
stridulus. 

Etiology. — There is still confusion as to the causation. One theory is that 
it is due to a poorly coordinated action of the respiratory muscles involved in the 
act of breathing. The epiglottis is deformed as a result, and inspiration then 
produces the peculiar crowing respiration of the affection. (Thomson.) 

Sometimes a narrowed, infolded and thinned-out epiglottis is found which 
can be observed by laryngoscopic examination to cause the peculiar sounds. 
Variot claims that the condition is found in the lymphatic diathesis and that it is 
caused by an enlarged thymus, his observations being confirmed by X-ray exam- 
inations. Others believe it to be a pure neurosis dependent upon an underlying 
nutritional defect. 

Symptomatology. — From birth there is heard mainly on inspiration a high- 
pitched rasping croak ; with expiration this is heard only with difficulty or not 
at all. Crying or excitement of any kind increases the stridor and even retrac- 
tion of the thoracic spaces. On the other hand, it is rarely audible during quiet 
sleep. The voice is not affected even in crying. There is no cyanosis produced 
by obstruction. 

Diagnosis. — This is founded upon the inspiratory stridor present since birth 
in a child otherwise unaffected as to development and who is not made sick or 
uncomfortable by the condition. Laryngoscopic examination or a direct exam- 
ination of the epiglottis can be quite often made in infants with a correctly- 
shaped tongue depressor. Laryngismus stridulus (p. 341) is found mainly in 
rachitic children, is rare before the dentition period, and is often associated with 
tetany. New growths of the larynx should be ruled out by careful examination. 

Course and Prognosis, — Up to the end of the first year the condition is at 
its worst; then amelioration begins, and at the second year it quite disappears. 
The physical condition is not affected, but superadded diseases of the respiratory 
tract are apt to have a fatal issue. 

Treatment. — The condition does not lend itself to any form of treatment, 
but the intubation tube and instruments for tracheotomy should be on hand if any 
respiratory disease complicates it. 

New Growths of the Larynx. 

Papillomata. — Although by no means common, they are not rare. They 
may be congenital or attributed to the specific fevers. Distinct continued hoarse- 
ness is the prominent symptom. As the growth later on causes obstructive 
symptoms, dyspnea or suffocative attacks follow. 

The diagnosis may be made or confirmed by the direct method, using either 
the instruments of Jackson or Bruning. 

The latest method for work in the larynx is that of Killian suspension 
laryngoscopy. A case may be suspended for one-half or three-quarters of an hour. 
Rectal anesthesia should be used in this type of work. 

For the examination of the trachea and bronchi we have the Jackson instru- 
ment, a hollow tube with an electric lamp at the distal extremity, or the Bruning 
instrument, slightly modified by Kahler of Vienna. This last instrument has a 
universal handle to which various sized tubes can be attached for direct exam- 
ination of the larynx, trachea, bronchi, esophagus, and stomach. 

The Bruning type of instrument has its warm advocates, the main advan- 
tage being successful and continual illumination at the end of the tube. The 
small lamp at the end of the Jackson tube is too easily covered with blood, mucus 
or pus. 



CHAPTER XXIV. 

DISEASES OF THE LUNGS AND PLEURA. 

Acute Bronchitis. 

This is an acute inflammation of the mucous membrane of the large 
and medium-sized bronchi. It is a frequent disease in early life. 

Etiology. — Bronchitis results as an infection following lowered 
resistance from exposure, malnutrition, rickets, enlarged tonsils, adenoids, 
valvular disturbances, or following the infectious diseases. Irritating gases 
or dust particles may also cause a form of bronchitis. The bacteria 
found in the secretions are many and varied and of the types commonly 
found in the bronchial tract. 

Symptomatology. — The symptoms usually begin with a coryza, or 
follow an obstinate rhinitis or tracheitis. There is a hard, dry cough which 
soon becomes loose as more mucus is produced. The pulse and temperature 
are slightly elevated, rarely over 101° F. during the day but may be a 
degree or two higher in the evening, while the respirations are always higher 
than normal. The child, as a rule, does not complain and may be quite 
willing to be about ; infants, however, are often restless and irritable and 
vomiting may result from an attack of coughing. The stools are rarely 
normal, either constipation or loose stools being observed. It must be 
recollected that the sputum is swallowed by infants and children up to five 
years of age. The disease tends to recovery in from five days to a week. 
Severer forms are seen which are due to involvement of the smaller bronchi 
(formerly termed capillary bronchitis) in which the s}^mptoms are more 
pronounced and there is some dyspnea. The pulse and respiratory ratio 
may be somewhat disturbed and a pneumonic process result from infection 
of the alveoli. 

Physical Signs. 

Inspection. — Breathing is quickened, and there may be recession of 
the softer parts of the chest wall, especially in rickety children. 

Percussion. — Xo changes from the normal. 

Auscultation. — Exaggerated puerile breathing and rales of varied 
character, according to the location of the inflammation, are found. Large, 
coarse rales (ronchi) over the larger tubes and moist rales with finer 
rales over the smaller bronchi may be noted. 

Tactile fremitus is often distinct in infants when the secretions are 
viscid. 

343 



344 • DISEASES OF CHILDREN. 

Diagnosis. — The differential diagnosis is to be made from broncho- 
pneumonia, in which the temperature is higher with a disturbed pulse and 
respiration ratio, by the grunting respiration and dyspnea. The physical 
examination does not elicit dullness and subcrepitant rales as in pneu- 
monia. In pulmonary collapse there is dullness on percussion and absence 
of respiratory murmur and subnormal temperature. 

Prognosis. — This is usually good except in cases of rickets and after 
the infectious diseases, when pneumonia is likely to follow. Young infants, 
however, may die from a simple bronchitis when the tubes become obstructed 
with mucus, cyanosis and cardiac failure resulting. 

Treatment. — Eest for the patient and fresh air are necessary require- 
ments. A change to a dry climate will often alone effect a cure. The 
bowels should be opened with a grain of calomel in divided doses or one or 
two drams of castor oil. The diet is to be restricted and water freely given. 
If the temperature is unduly high and is causing discomfort, an alcohol rub 
is indicated. The use of hot poultices and jackets are mentioned only to be 
condemned, and the same may be said of the so-called syrupy cough mix- 
tures. If the secretions are persistently dry and the cough harassing, the 
Liq. ammonia anisatis in 3 to 5 drop doses in water to a child of five years 
or in the following mixture will prove useful, and will not disturb the 
digestive apparatus. 

I£ Liquor ammonii anisatis 3j 

Potassii iodidi gr. iv 

Glycerini gss 

Aquae q.s. ad. §ij 

Misce et signa. — 3j every three hours. 

The aromatic spirits of ammonia in five to ten drop doses, diluted, is also 
effective. 

Do not give muriate of ammonia to children. If at night a sedative 
is necessary to allow the child to sleep, appropriate doses of any of 
the following drugs may be given: Codein, Tincture opii camphorata, 
Antipyrin, or Sodium bromid. 

The room is to be kept well ventilated and the temperature preferably 
not above 70° F. An enforced rest in bed with no further treatment than 
a free catharsis is often alone curative. If the child has adenoids and 
enlarged tonsils, these should be removed at a later date to prevent subsequent 
attacks. 

Chronic Bronchitis. 

Etiology. — This may result from repeated attacks of the acute form. Chil- 
dren suffering from disease of the heart, kidneys, or liver are prone to pulmonary 
congestion, and thus acquire a chronic bronchitis. 

Rachitic children, those with a tendency to lymphatism and adenoids, and 
those with a tuberculous diathesis are often afflicted with chronic bronchitis. 

Symptomatology. — Fever is rarely observed and the child is not incapaci- 
tated from its play. The cough is often mistaken for pertussis, and is worse at 



DISEASES OF THE LUNGS AND PLEUKA. 345 

bedtime and upon arising. Older children expectorate an abundant frothy mucoid 
secretion, while younger children may swallow or vomit it. 

The physical signs are more marked when there is an accumulation of mucus 
and almost disappear in the quiescent stage. During the warmer months the 
cough may entirely disappear. 

Diagnosis. — From pertussis the differential diagnosis is made by the course 
and the paroxysmal attacks followed by vomiting. Tuberculosis may be differ- 
entiated by the tuberculin tests, the absence of fever, and the physical signs. 

Prognosis. — The prognosis bears a distinct relation to the etiological factor. 
If this can be remedied, as adenoids for example, much improvement may be 
expected. If there is glandular enlargement present or a tuberculous tendency, 
the outcome is not as hopeful. 

Treatment. — First remove if possible the underlying cause. Climatic treat- 
ment is often productive of good results. Tonics such as the syrup of the iodid 
of iron and cod-liver oil are serviceable. Carbonate of guaiacol in 3 to 5 grain 
doses in sugar of milk is beneficial for the cough. 

Pulmonary Collapse. 

Collapse of small areas of the lung occurs frequently and quite easily in 
infancy. The condition may occur in cases of bronchitis and in obstruction or 
stenosis of the upper respiratory tract or of the bronchi. 

Children with rickets are particularly predisposed, as the condition is 
dependent upon the yielding nature of the thoracic walls in early life. 

Symptomatology. — Superficial areas cannot be detected by physical exam- 
ination, nor do they produce any noticeable symptoms. Larger areas give rise 
to very marked and sudden symptoms. The child's condition suddenly changes to 
one of cyanosis ; his restlessness is dependent upon the inability to get air ; the 
breathing is extremely shallow and gasping; the supraclavicular spaces show 
marked recession with each effort of breathing. A fatal issue may be preceded 
by convulsions. 

Physical Examination. — Dullness, or dullness to flatness, over the collapsed 
area is noted. On auscultation, the breath sounds are entirely absent. The cry- 
ing voice is diminished. Areas of compensatory emphysema are present, usually 
in the upper portion of the chest. These signs, with the history of sudden onset, 
in a child suffering from a previous pulmonary condition, should cause no con- 
fusion in the diagnosis. 

Treatment. — A full hot mustard bath followed by artificial respiration may 
be employed in desperate cases. Holding the infant by the heels may succeed in 
producing an effort at deep inspiration, and will dislodge any considerable amount 
of mucus that may have acted as the cause of the collapse. The production of 
emesis by the introduction of the finger in the throat should be tried. If the 
secretions are still found to be considerable in amount after amelioration of the 
collapse, a hypodermatic injection of atropin sulphate 1/300 gr. will be efficacious. 
A trained attendant should be placed in charge. 

Emphysema. 

Emphysema in some degree occurs very frequently in infants and children 
suffering from bronchial affection. 

Acute emphysema occurs most frequently in bronchitis, bronchopneumonia, 
pertussis, stenosis of the larynx, and pulmonary collapse. It is produced by 
overdistention of the weak elastic tissue of the alveoli when the glottis is closed 
in violent efforts of coughing. 

Children suffering from chronic bronchitis frequently have an accompanying 
emphysematous condition which does not recede until some time after all evi- 
dences of the bronchitis have disappeared. 

The condition of chronic emphysema is not often seen in childhood. The 
diagnosis is based upon the abnormally full and rounded chest, the hyperresonant 
D >te on percussion, the diminution of the area of relative cardiac dullness and 



346 DISEASES OF CHILDREN. 

the sonorous and sibilant rales heard all over the chest with unduly prolonged 
expiration. 

The prognosis and treatment are mainly those relating to the underlying 
conditions. 

Bronchial Asthma. 

This is a disease not common to early life and is due to a spasmodic 
contraction of the bronchial tubes as a result of some form of pathological 
stimulation of the bronchial muscles. 

Etiology. — Salter records 225 cases, among which 11 began the first 
year of life, and 60 as occurring from the first to the tenth year of life. 

Bronchitis is, in the majority of instances, the predisposing disease. 
Nasal obstructions, especially adenoids, are important etiological factors. 
They were present in 47 per cent, of La Fetra's cases. The relation of 
asthma to various forms of protein poisoning must not be forgotten. Egg 
white, e.g., causes acute asthmatic attacks in some children, usually with 
evidences of a mild anaphylaxis. 

Symptomatology. — ■ The attack may begin with a fairly pronounced 
bronchitis which lasts for several days; then there may be suddenly super- 
added dyspnea with its accompanying rapid respiration, anxious expression, 
and rarely cyanosis. 

Inspection of the chest during the paroxysm sIioavs retraction in the 
suprasternal and supraclavicular spaces, and the activity of the accessory 
muscles of inspiration. 

Auscultation. — Sibilant and sonorous rales are heard both during 
inspiration and expiration all over the chest. 

Percussion. — A hyperresonant note is elicited during the height of 
the attack. There is rarely any temperature unless the attack has closely 
followed an acute bronchitis. It rarely rises above 102° F. 

Blood examinations may be of assistance from the standpoint of dif- 
ferential diagnosis. Polymorphonuclear eosinophiles are increased in 
number, while in prolonged subacute cases a relatively lower eosinophilia 
is found. Scarification as for the von Pirquet test and the introduction of 
a small quantity of egg albumin into the site will result in a wheal if the 
case is one of egg anaphylaxis. 

Treatment. — Adenoids, enlarged tonsils, and other obstructions to 
proper breathing must be removed. Attacks of bronchitis are to be guarded 
against. A careful process of hardening by hydrotherapy or a change of 
environment may be necessary to prevent repeated attacks. Careful over- 
sight of the diet must be observed and indigestion avoided. The sugars 
and meats are the principal offenders. 

The indication for the treatment of the acute attack is the relief of 



DISEASES OF THE LUNGS AND PLEURA. 347 

the bronchial spasm. For this purpose a combination of the iodids and 
bromids is of distinct service. The bowels should be emptied with a 
soapsuds enema, and if there is any history of indiscretion in diet, an 
emetic dose of the wine or the syrup of ipecac given. 

Atropin 1/500 of a grain for a two-year-old child may be necessary for 
relief in severe cases. The syrup of the iodid of iron is valuable following 
the attack. 

Acute Bronchopneumonia. 

(Lobular Pneumonia, Catarrhal Pneumonia, Capillary Bronchitis.) 

This is perhaps the most common disease of infancy and is very often 
a secondary manifestation. 

Bronchopneumonia occurs most frequently in early life, and is second- 
ary to an involvement of the bronchial tubes. 

It is most often met with during the first two years of life, and is rarely 
seen after the sixth year. Bronchitis, the infectious diseases, especially 
measles, pertussis, influenza, diphtheria, and scarlet fever, are the predis- 
posing causes. Children with rickets, marasmus, syphilis, nephritis, and 
gastroenteritis, especially if they live in bad hygienic circumstances, have 
their resistance lowered, and are thus predisposed. Infants in asylums and 
institutions are especially prone to the affection. The pneumococcus of 
Frankel, Friedlander's bacillus, strepto- and staphylococci, and the bacterial 
flora of the nose and mouth are the exciting causes. 

Pathology. — The pneumonic areas result from extension of the 
inflammation through the bronchial walls and from the bronchial walls 
themselves into the peribronchial tissue. Thus not only the alveoli to 
which the bronchial tubes lead are involved, but also those which surround 
the tube. The alveoli become invaded by the bacteria and distended with 
white blood-cells, and contain some fibrin and red blood-cells. The small 
patches soon coalesce and become the size of a half-dollar or even in excep- 
tional instances involve the greater part of one lobe. On cut section, the 
bronchioles are found partly dilated and mucopurulent exudate flows out 
on pressure. The bronchial glands at the root of the lung may be infiltrated 
and an increase in the interstitial tissue is found in the older cases. 
Pleuritis is seen with any considerable area of pneumonia. Accumulations 
of fluid, small in amount, are not uncommon at autopsy. 

Symptomatology. — There are few diseases in which the symptoms 
may be so varied as in bronchopneumonia. The following description will 
show how varied the symptomatology may be, and what wide differences 
are found in the physical signs. The disease may be ushered in with 
vomiting or high temperature. On the other hand, fever may be absent or 



348 DISEASES OF CHILDREN. 

extremely low throughout the disease. The temperature in characteristic 
cases is markedly irregular. There usually is restlessness, rapid breathing, 
and a cough which may be severe or scarcely noticeable. If the disease 
follows, as it usually does, an attack of bronchitis, all the s}-mptoms which 
were present are exaggerated while the breathing becomes labored and the 
temperature increases. The cry is stifled and an expiratory grunt which 
is quite characteristic of acute lung involvement is heard. The pulse rate 
is much increased, rising to 120 or 180, and is small in character. The 
respirations are increased to 60 or 80, and the effort made to get enough 
oxygen is shown at the peripneumonic groove and by the dilated alae nasi. 
If a considerable portion of the lung is involved, cyanosis in the lips or 
finger-nails is observable. The child feels distinctly sick; it may refuse 
food, but usually takes water eagerly. The tongue is dry and coated. The 
dyspnea increases, and the cough may be harassing and suppressed. The 
pulse becomes weaker, and the hands and feet are cold. Sleep is fitful and 
constantly disturbed by efforts to cough. If the disease progresses and the 
temperature remains persistenly high, stupor, delirium, or even coma may 
ensue. The pulse may become irregular. The heart action may give indi- 
cations of myocardial changes and convulsions may precede a fatal termi- 
nation. Improvement or retrogression of the affection is shown by a 
decreased number of respirations and a more normal pulse-respiration ratio. 
The character of the pulse improves, the infant takes some interest in his 
surroundings, sleeps more, and finally takes nourishment eagerly. 

Physical Signs. — The objective symptoms vary as greatly as the sub- 
jective signs. The examiner must not be astonished if he finds signs not 
commensurate with the degree of prostration. 

Palpation. — Little or no satisfactory information is obtained. How- 
ever, the apex beat of the heart may be located and pain on handling 
appreciated. 

Inspection. — Bapid, labored breathing is noted. The alaa nasi are 
dilated, and there may be some degree of cyanosis visible. Eetraction of 
the peripneumonic groove is observed in advanced cases. 

Auscultation. — Auscultation with inspection are of the greatest value. 
A pause between inspiration and expiration occurs, and can be appreciated 
if the child is quiet or sleeping. The bronchitis present will be revealed 
by coarse, moist rales, often sonorous in character. Subcrepitant and crepi- 
tant rales with diminished breathing heard at the end of inspiration over 
a limited area reveal the location of the pneumonic involvement. These 
are best heard when the infant is crying or during coughing. The exami- 
nation should not cease without sufficiently forcible respiratory efforts on 
the part of the infant. Prolonged expiration and bronchial breathing are 



DISEASES OF THE LUNGS AXD PLEURA. 349 

obtained when the area of the pneumonia is recent. Yocal fremitus may 
be heard while the child is crying, over larger areas of consolidation. The 
examiner must not fail to use a stethoscope with a small bell, and 
must not omit in his search the axillary region, for the first signs are often 
found there. 

Percussion. — Light percussion is a desideratum. Dullness may be 
appreciated if present and points to consolidation. Areas giving a hyper- 
resonant note are obtained over portions of the lung in which a compensatory 
emphysema has occurred. 

The Important Symptoms in Detail. Temperature. — ■ As a rule, 
the temperature is high in the beginning, 103° to 104° F., although periods 
of remission are not uncommon. The disease ends by lysis and the curve 
shows the gradual return to the normal. Xo typical temperature curve 
can be presented because of the intermittent and remittent character of 
the fever. Sudden high rises may indicate a complication or an added 
area of pneumonia. Marasmic infants frequently are seen with little or 
no fever, or they may even have a subnormal temperature. 

Respirations. — The normal ratio of pulse and respirations, 1 to 3, 
or 1 to 4, may be so far disturbed as to reach 1 to 2.5 or 1 to 2. The 
severity of the dyspnea can be judged by the amount of recession at the 
sternal space and diaphragmatic attachments. The breathing may be irreg- 
ular or simulate the Cheyne- Stokes type. Coughing or crying markedly 
accelerates the respirations, and if pain is present it is increased. The 
expiratory grunt is almost pathognomonic. It is produced in early life by 
only three conditions, namely, pneumonia, pleurisy, and a very acute indi- 
gestion. In rachitic children the respirations are especially increased and 
extremely shallow. 

Heart and Pulse. — The pulse is small and frequent. When the 
temperature is high the pulse may be as rapid as 180 to 200. Its numerical 
value is not of as much moment as the character of the pulse compared 
to the action of the heart. The second sound is often accentuated, and 
anemic murmurs are heard during convalescence. 

Digestive Tract. — Especially to be feared is the distention of the 
abdomen with gas. The meteorism impedes the movements of the dia- 
phragm and adds greatly to the discomfort of the infant. Vomiting is 
often one of the initial symptoms. Diarrhea is more frequent in the 
nursling, while constipation is the rule with the artificially fed. 

Cerebral Symptoms. — Occasionally stupor is seen from the first day 
of the disease. A convulsion may usher in the disease or purposeless move- 
ments may appear at any time in its course. Meningitis may be in conse- 
quence suspected. True symptoms of cerebral involvement may precede a 



350 DISEASES OF CHILDBED. 

fatal termination. The ear should be examined in suspected cases, and 
lumbar puncture made for purposes of verification. 

Clinical Forms of the Disease. — Disseminated bronchopneumonia is 
the form in which there are small areas scattered over different parts of 
the lung. They do not coalesce, and varying physical signs are found in 
the several patches. The asthenic form is frequent in marasmic or rachitic 
infants, and it generally accompanies a gastrointestinal infection. There 
is little or no fever in this type, and the course is protracted and often ends 
in death. 

Bronchopneumonia Complicating the Infectious Diseases. — With 
Pertussis. — To the symptoms of bronchitis present are added the objective 
signs of a pneumonia usually of the disseminated type. The temperature 
rises abruptly and often to 105° F. The dyspnea is marked and cyanosis 
appears early. The complication seriously affects the prognosis. Tuber- 
culosis may follow in its wake if the child recovers. The course is usually 
long and tedious, remissions being very common. During the course of 
the pneumonia the spasmodic or paroxysmal character of the cough is not 
so marked as in uncomplicated pertussis. 

With Measles. — If, after the eruption of measles when the fever has 
subsided, there is an abrupt rise of temperature and on physical examina- 
tion there are found crepitant and subcrepitant rales over localized areas, 
bronchopneumonia may be diagnosticated. The cough is increased; it is 
more frequent and dyspnea is more marked. The pulse and respirations 
are increased. The somnolent and apathetic state is again present. 

With Diphtheria. — The pneumonia is more apt to occur in cases 
having laryngeal involvement, especially those which have necessitated 
operative interference. It is one of the commonest causes of death after 
intubation. Bronchiectasis or pulmonary abscess may develop in the more 
chronic forms. 

With Other Exhausting Diseases. — As a terminal infection, 
bronchopneumonia may occur in a variety of diseases common to childhood, 
more especially those that are of bacterial origin, such as typhoid and 
gastroenteritis. Where a general sepsis is present, it is sometimes only 
discovered at necropsy. 

Complications. — As has been stated above, the disease is in itself 
mainly secondary to some other process. During its course there may 
develop an involvement of the ear, heart, peritoneum, pleura, or meninges. 
Following cases of delayed resolution, brochiectatic cavities, abscesses, and 
fibroid changes may develop. 

Differential Diagnosis. — From acute bronchitis it may be distin- 
guished by the milder symptoms, the lower grade of temperature and pulse, 



DISEASES OF THE LUNGS AND PLEUEA. 351 

and the less disturbed pulse-respiration ratio. Xo localized area of 
bronchial breathing, bronchophony, or fine crepitant rales will be found. 
Instead there will only be present numerous coarse and fine bronchial rales. 

From Lobar Pneumonia. — If occurring in an infant, and there is 
a history of a primary infectious disease, bronchopneumonia is rather to 
be suspected. In the lobar type the temperature is more constantly high 
and drops by crisis, while the course is invariably shorter. The physical 
signs may not be distinctive until consolidation has taken place. Leuko- 
cytosis is higher and persists until the temperature falls at crisis. 

Froai Tuberculosis. — A bronchopneumonia of long duration is often 
regarded as a tuberculous process. It is to be differentiated by the tuber- 
culous aspect of the child, the greater wasting and possibly by the signs of 
tuberculosis elsewhere. A negative von Pirquet test is of value in 
differentiation. 

Course and Prognosis. — The course varies from two to six weeks, as 
a rule, and only rarely ends by crisis, lysis being the rule. A pneumonia 
superimposed on gastroenteritis or other debilitating diseases is apt to be 
prolonged and to leave the child in an extremely emaciated and asthenic 
condition. This is always a very serious disease. The prognosis is always 
unfavorably influenced when it complicates poorly nourished infants with 
infectious or constitutional diseases. The younger the child the more un- 
favorable the prognosis. Artificially fed infants in institutions and those 
with rickets or whooping cough must be regarded as especially unfavorable. 
The signs upon which the practitioner may base a favorable prognosis are 
undisturbed heart sounds, absence of marked dyspnea, willingness to take 
nourishment, and undisturbed gastrointestinal tract. On the contrary, if 
vomiting and diarrhea, irregular breathing, meteorism, and cerebral symp- 
toms develop, the outlook points to a fatal issue. 

Treatment. — The high mortality of this disease will be reduced if the 
disease is treated rationally. The vital resistance of the infant must be 
supported or increased so that the self-limited disease may terminate favor- 
ably. Fresh air, proper diet, hydrotherapy, and stimulation, when appro- 
priately used, will conserve the resisting powers. Anti-pneumococcic sera 
are worthless unless prepared for the particular type of pneumococcus 
present. 

Aerotherapy. — The patient should be placed in its crib in a large 
sunny room, the windows of which are opened to admit an abundance of 
fresh air. Light and warm clothing should be worn in the colder months, 
hot-water bags or an electric thermophor being placed at the child's feet if 
the extremities are cold. A screen may be used to shield the patient from 
a direct rlrausrht. 



352 DISEASES OF CHILDREN. 

The diet should be a modification of the previous feedings. With the 
breast fed, reduce the intervals and give water before nursing. The food of 
the artificially fed should be reduced with gruel. Older children are 
allowed milk, gruels, broths, albumin water, and orangeade. 

The temperature should be controlled by hydrotherapeutic measures 
if it is causing unrest, insomnia, or cerebral symptoms. A temperature of 
lOi F. in one infant may cause less distress than a temperature of 101° F. 
in another child. A daily cleansing bed-bath should be given in all cases. 
The milder measures for the reduction of temperature should be first at- 
tempted, — for example, an alcohol sponge-both (one part to four) will 
usually reduce the temperature a degree or two, and also has a tonic effect 
upon the patient. The water may be luke-warm, but its alcoholic strength 
may be increased if the desired effect is not obtained. The naked infant is 
wrapped in a flannel blanket and one portion of the body after another is 
sponged, and by gentle friction the liquid made to evaporate, and thus the 
cooling effect is obtained. Such a bath should take from ten to twenty 
minutes and is often followed by relaxation and a refreshing sleep. Com- 
presses wrung out of water at 90° F. may be placed about the chest and 
renewed hourly almost without disturbing the patient. The cool pack will 
be required in sthenic cases with high temperature and delirium. Ice-bags 
to the head, while effective in reducing temperature, are dangerous unless 
cautiously employed under the direct supervision of a competent nurse. 
Weak, badly nourished infants or those with a subnormal temperature are 
preferably given a hot mustard bath with the water at 105° F. A cheese- 
cloth bag containing an ounce of mustard is drawn through the water and 
the infant is removed when the skin reddens from the counterirritant. 

Local Applications. — •Mustard pastes are especially effective in the 
beginning of the disease and should be applied directly over the affected 
area in the strength of one part mustard to six or seven of flour. Direc- 
tions should be given as to the size and frequency of the application. When 
the skin is well reddened the application should be removed. If the area 
becomes blanched within four hours a second application may be made. 
Warm poultices and oiled silk jackets are only mentioned to be deprecated. 

Medication. — No drug, however harmless, should be prescribed with- 
out a distinct indication. The symptoms will in greater part be relieved 
by sponging and local applications. If the bowels are constipated an initial 
calomel purge in divided doses or an enema may be given. Sedatives for 
the cough as a routine measure, especially in the form of syrups, tend only 
to produce fermentation and retard progress. A stimulating expectorant 
in the form of the ammonia preparations, as the aromatic spirits or the 
Liq. ammonia? anisati, will promote freer secretion if required and also tend 



DISEASES OE THE LUNGS AND PLEURA. 353 

to support the he-art. A harassing purposeless cough which prevents sleep 
can be profitably controlled with small doses of Dover's powder (J gr. to 
one-year-old child, q. -i h.). 

Judicious stimulation of the heart is one of the most essential parts of 
the treatment. The physician must be guided by the action of the heart 
when the child is quietly sleeping. A rapid feeble pulse rate, weakness of 
the heart sounds, and signs of failing compensation are indications for drug 
assistance. 

Strychnin well meets many of these indications, unless the nervous 
symptoms are a prominent feature. One three-hundredth of a grain may 
be alternated with another suitable cardiac stimulant every four hours for a 
year-old infant. The tincture of strophanthus in drop doses every three or 
four hours is an effective remedy having no ill effects on the digestive tract. 
Alcohol in the form of brandy, if used at all, should be given well diluted, 
but never continued for any length of time, as nausea or vomiting almost 
invariably results. Camphor (grs. 1 to 10 minims of sterile olive oil) 
should be used hypodermatically in desperate cases. If the stomach does 
not retain food or medication, the needle must be used if stimulation is 
imperative. 

Hypostatic Pneumonia. 

This form of pneumonia is found as a secondary affection in many poorly 
nourished children, and especially in those who are brought to children's hospitals 
for treatment. It is no doubt a result of lowered vital resistance. The post- 
mortem examination shows an area of dark solid or semisolid lung tissue along 
the posterior borders of the lung, which on cut section is dark, grumous, and 
edematous. A serosanguinolent fluid exudes on pressure. The symptoms are 
those of a low-grade pneumonia. 

Treatment. — Combat the accompanying asthenia with stimulants, such as 
strychnia and caffein, and treat the original condition. All such children need 
particularly to be removed for a few hours from the sick-room and their position 
in the crib is to be frequently changed. They often breathe better if the chest is 
elevated on a pillow. 

Lobar Pneumonia. 

(Croupous Pneumonia.) 

A pneumonia affecting a lobe or a considerable part of a lobe and is 
caused by the diplococcus of Frankel. 

Etiology. — This form is commonly seen in children of three or more 
years of age and is not as rare as has been thought in the second year of life, 
and is rarely secondary, as is bronchopneumonia. 

Pathology. — The apices are in our experience more frequently first 
affected in children, and then the bases. The disease passes through the 
four stages just a? it does in adults; i.e., congestion, red and gray hepatiza- 
tion, and resolution. 
23 



354 DISEASES OF CHILDREN. 

Symptomatology. — The onset is sudden, most frequently with a chill 
or chilly feelings or convulsions, followed quickly by high fever and rapid 
breathing. In some cases the nervous symptoms mask the pulmonary con- 
dition, simulating meningitis. The temperature rises to 103° or 105° F., 
and remissions are only slight and usually take place in the morning. The 
pulse is relatively high and full. In severe cases the prostration is com- 
plete, with delirium and semicoma. The child refuses food, is thirsty, and 
may complain of pain on coughing, or of abdominal pain. The cough may 
be slight or even absent for a few days, but toward the end is quite marked. 
In older children rusty sputum is sometimes observed. The disease ends 
by a crisis, but this is not always sharply denned. It may end also by 
pseudo-crisis or lysis, especially in those children who have previously been 
enfeebled. 

Physical Signs. — Inspection. — Flushed face, dilating abe nasi, and 
rapid respirations. 

Auscultation. — Bronchial breathing is noted in the early stages and 
later fine subcrepitant rales; when resolution takes place, bronchovesicular 
breathing and many moist rales may also be present. 

Percussion. — 'Dullness over the affected area diminishing as the dis- 
ease progresses and resolution takes place. 

Palpation. — Increased fremitus. 

Complications. — More or less pleurisy of a dry character is present 
in nearly every case. Meningitis or meningismus is often secondary in the 
grave or fatal cases. Otitis is not rare, while pericarditis and peritonitis 
are sometimes seen. Empyema should always be considered if convalesence 
is protracted. 

Diagnosis. — The sudden onset, more constant high fever and physical 
signs of consolidation differentiate it from a bronchopneumonia. A cen- 
tralized pneumonia is often puzzling and causes a suspicion of typhoid 
fever or malaria. A blood examination will then assist the diagnosis. In 
the central pneumonia the process is enclosed in healthy lung tissue, and 
the physical signs may not appear for several days, but the rational signs 
plus the fairly characteristic symptoms will fix the diagnosis. The pain 
referred to the abdomen has led to a mistaken diagnosis of appendicitis. 
Examine the lungs particularly for a centralized process. 

Prognosis. — The prognosis is very good. 

Treatment. — This has already been spoken of under bronchopneu- 
monia. It is essentially the same, but may be more vigorously pursued, as 
the cases are generally of a more sthenic type. Complications by extension 
into the ear must be guarded against. Eepeated examinations of the ear- 
drums may be necessary. 



DISEASES OF THE LUNGS AXD PLEURA. 355 

Pleurisy. 

Dry Pleurisy. — This is an inflammation of a localized area of the pleural 
surface, usually in conjunction with a pneumonic process, over infarcts or exten- 
sion from a tuberculous pneumonia. These lesions are seen frequently post- 
mortem ; the pleural surface is found to be dull and lusterless with the adhesions 
firm or fibrinous. 

Symptomatology. — To these adhesions the pain accompanying a pneumonic 
process may be ascribed (a pleuritic friction rub is heard on auscultation over 
the consolidated area). 

The pain is sharp and lancinating, and usually produced or noticed after 
coughing. In older children it is evidenced at the end of a deep inspiration. 

Treatment. — Outlined under Serous Pleurisy. 

Serofibrinous Pleurisy. 

This form also results from extension of infection from a tuberculous 
or pneumonic process. The fluid is usually found to be sterile on ordinary 
culture media, but in cases in which perfected methods have been employed 
the tubercle bacilli may be found. 

Infants rarely have this form of pleurisy; it is more commonly found 
after two years of age. The weight of opinion inclines to the belief that 
previously infected bronchial lymph-glands are the source of infection. 

Pathology. — On the surface of the pleura is found a fibrinoplastic 
exudate, sometimes thick, but usually thin and soft. The fluid which 
exudes is yellow or yellowish-green in color. The lung may be found col- 
lapsed in whole or in part. Sacculated effusions of serous fluid are not as 
common as the purulent. The bases of the lung form the common site; 
occasionally both bases are affected simultaneously. 

Symptomatology. — . For several days there is fever, cough, chilliness 
and more or less pain referred to the chest. Gradually the child is seen to 
play less, is listless and apathetic. The temperature is irregular, fluctuat- 
ing from 101° to 102° F. Difficult breathing is now apparent. The pain, 
it should be recollected, may be referred to the abdomen. Headache, con- 
stipation, and coated tongue are usual manifestations. The respirations 
and pulse are accelerated, but the ratio is not seriously disturbed unless the 
effusion is large. In the latter event pain is usually diminished or absent. 
Loss of flesh is now apparent, dyspnea is marked, and the child prefers to 
lie on the affected side. 

Physical Signs. — Inspection. — Movement may be impaired if the 
effusion is large. The cyrtometer may show greater measurement on the 
affected side. 

Palpation. — Vocal fremitus is diminished in large collections. 

Auscultation. — The respiratory murmur is diminished and bronchial 
breathing, distant in character, may be heard, and over the base all breath 
sounds mav be absent. The breath sounds, if heard at all, diminish from 



356 DISEASES OF CHILDREN. 

the spine toward the axilla. Friction rales may be heard at or above the 
fluid in older children. The vocal resonance is diminished over the fluid 
itself, but does not assume the characteristics observed in adults. 

Percussion.— A dull or dull to flat note is elicited by percussion, 
together with a sense of resistance to the percussing finger. Above the fluid 
a tympanitic note may be heard. 

Large effusions may displace the heart, liver and spleen especially in 
older subjects. Aspiration confirms the diagnosis. (See article on Em- 
pyema, p. 357.) 

Prognosis. — The fluid has a tendency to spontaneous absorption, pro- 
vided purulent changes do not take place, and death rarely results from 
the effusion itself. The prognosis is unfavorably influenced if the fluid is 
due to a tuberculous focus. 

Treatment. — Rest in bed is imperative. If the fluid is small in 
amount, free bowel action, plus the use of diuretics as the Liq. ammonii 
acetatis with a moderately dry light diet, may suffice for a cure. In large 
effusions, aspirate at once, then follow the plan outlined above. The Liq. 
ferri et ammonii acetatis serves very well as an after-treatment combined 
with a life in the sunlight and fresh air. Aspiration should be performed 
according to the directions given under empyema on page 358. If the 
effusion is copious a Potain aspirator or the siphonage method advocated bv 
Huber will be found advantageous. (See Fig. 103.) 

Empyema. 

Empyema is known to be much more frequent, both relatively and 
absolutely, in infancy and childhood than in adult life. Statistics show us 
that 40 per cent, of pleurisies in infancy and childhood are purulent, while 
only 5 per cent, result in a suppurative pleuritis in adults. Yet in spite of 
this fact it has been mainly studied pathologically and clinically from 
adult life. 

The great majority of cases of empyema follow lobar pneumonia in 
children. Although the infectious diseases and pyemia may be complicated 
by it, some inflammatory process in the lung or pleura has generally pre- 
ceded the suppuration. 

The pneumococcus we find present in the greater number of cases in 
almost pure culture. The staphylococcus and streptococcus occur in cases 
from which thin pus with little fibrin is withdrawn. We are as yet uncer- 
tain as to the number of cases due to the tubercle bacillus ; as this organism 
is difficult to find in the exudate, and is often reported as absent when the 
subsequent course would clinically stamp the case as of the tuberculous 
variety. Bovaird believes that six per cent, of all cases are tuberculous. 



DISEASES OF THE LUNGS AND PLEUEA. 357 

The pus found in the average case of empyema is quite thick, creamy 
and odorless, with masses of fibrin of varying consistency floating in it. 
The fluid exudes quite slowly at first, and there is in the beginning an 
attempt made by nature to wall off this fluid by fine adhesions, with the re- 
sult that small pockets or sacculations are formed ; as the fluid accumulates 
in greater quantity, these septa are broken down and merged, and thus the 
fluid may fill the entire pleural cavity. 

Sacculation is frequent in children, and it is important to be able to 
recognize the condition at this stage, and treat the case early before much 
damage has been done. The fluid in cases of pleurisy with effusion slowly 
becomes slightly turbid, then seropurulent, and finally assumes pure pus 
characteristics : this change being accompanied by a corresponding increase 
in the number of bacteria present. 

A study of the charts of the empyema cases at the Post-Graduate Hos- 
pital in Xew York shows that the empyema develops about the fourth week 
after pneumonia, and that the average amount of pus is small (5 to 8 oz.). 
The most frequent complications were peritonitis, meningitis, pericarditis, 
and sepsis. 

Symptomatology. — If, in a case which has recovered from a pneu- 
monic process or from an infectious disease, there is not a. steady improve- 
ment in physical well-being, but instead a low-grade temperature, with 
increased number of respirations, accompanied by a slight hacking cough, 
pallor, sweating of the head, steady emaciation, and a marked leukocytosis, 
suspicion should be directed to fluid in the chest. 

In spite of these warning rational signs there is probably no other 
equally great pathological change anywhere in the body so often unsus- 
pected or overlooked. 

The physical signs of fluid in the chest of infants and children differ 
grossly from those of the adult. In the examination the possibility of 
encapsulated or sacculated effusions must be kept in mind which, as has been 
pointed out, may contain but little pus and still give marked subjective 
symptoms. In infants the chest may contain fluid and we may still obtain 
practically normal breath and voice sounds. 

Confirmatory physical signs above the fluid, at the level of, and over 
the fluid cannot always be obtained in young patients. Ellis' curve and 
obliteration of Traubes' space cannot be depended upon for assistance. 
Skoda's resonance may or may not be present. 

The main signs upon which reliance must be placed are marked dull- 
ness or flat up** on percussion over any area usually resonant, bronchial 
breathing, and marked resistance to the percussing finger, as distinguished 
from a corresponding point on the opposite side. These physical signs, 



358 



DISEASES OF CHILDREN, 



coupled with the rational signs above enumerated, should be sufficient justifi- 
cation for the introduction of the needle. An early diagnosis is of the 
utmost importance, and no diagnosis of empyema should be regarded as 
complete without exploratory puncture. If in addition to these physical 
signs we can elicit bronchial breathing over the area of flatness; relative 
immobility of the affected area and bulging, with displacement of the apex 
beat — then omission to puncture would be unjust to the patient. 

Exploratory Puncture. — The exploring 
syringe and needle should be of good caliber and 
length, as the pus may be thick and contain clots 
of fibrin. After proper sterilization of the syringe 
it should be tested to ascertain if it is still in good 
working order. The skin having been thoroughly 
cleansed over the affected area, and painted with 
iodine, the needle can be inserted somewhat above 
the lowest point of flatness. If the whole side is 
involved we can select the most favorable points; 
viz., in the sixth interspace in the posterior axil- 
lary line on the left side and the fifth interspace 
on the right side. If we keep in mind that the 
diaphragm rises higher in children than in adults 
and that the liver must be avoided on the right 
side we have a fair field for exploration. 

With the child held in the upright position, 
and its arm extended above its head, we can thrust 
the needle directly forward — noting at the same 
time the amount of force necessary to penetrate 
the pleura and partly withdraw the plunger. If 
no fluid appears point the needle upward, and then 
if necessary downward, and you will have explored 
the suspected area thoroughly and avoided the pos- 
sibility of escaping encapsulated pus or penetrating a thick fibrinous mass. 
This method, if a strong needle is used, presents no dangers, and saves the 
child from repeated explorations, when we feel morally certain that fluid is 
present but fail to get it at once with the syringe. The X-ray may also 
assist in puzzling cases. 

If possible, examine the exudate for bacteria, as the bacteriological 
findings, coupled with the duration of compression, the amount of pleural 
thickening and ability of the patient to resist the effect, will determine the 
prognosis. 



(£ 



Fig. 102. — Aspirating 
syringe suitable for 
thoracentesis, etc. 



DISEASES OF THE LUNGS AND PLEUEA. 



359 



When a clear, straw-colored fluid is withdrawn we can afford to wait 
and watch for signs of recession of the fluid. If this does not occur, or the 
temperature curve later shows septic characteristics, puncture again, and 
the fluid will now probably show purulent changes. When the first ex- 
ploration shows a seropurulent or purulent discharge operative interference 
should not be delayed. 

Treatment. — Aspiration should 
be employed for temporary relief of 
dyspneic symptoms only . Incision 
and drainage aseptically performed 
under light general or local anes- 
thesia give better results. Siphon 
drainage in infants and very young 
children as illustrated in Fig. 103 
is then practised and the tubes re- 
tained until the discharge is quite 
moderate. The operation of rib re- 
section is preferable in all cases of 
empyema except in very young in- 
fants whose physical condition war- 
rants any operative interference. The 
general subperiosteal operation of the 





Fig. 103. — Siphon drainage after 



Fig. 104.— Spool made of 
soft rubber for drainage. 



eighth or ninth rib in the postaxillary line is no more dangerous than incision 
and can be as quickly performed, especially when we recollect that in the 
former operation we are often obliged to pass the finger through the in- 
cision to free the fibrinous masses. By resection we secure ample drainage 
space, are not hindered with clogged tubes, and what is more important 
we hasten the time of recovery of the patient. Xo permanent deformity 



360 DISEASES OF CHILDREN. 

results, as it is necessary to remove only one inch of the rib and the perios- 
teum is preserved. The mortality is reduced also to one in seven. Instead 
of the double drainage-tube the spool tube (see Fig. 104) of suitable size 
for the patient is used. This has the advantage of being least irritating to 
the pleural surfaces, and in action simulating a valve, allows the lung to 
expand with coughing efforts, and furthermore can be easily cleansed with- 
out painful removal. This tube should be removed as soon as the discharge 
becomes serous. The sinus will then still be fresh and tend to close, leaving 




Fig. 105. — Blowing colored fluid from one bottle to another 
favoring lung expansion. 

surprisingly little deformity. Irrigation except in extremely fetid neglected 
cases is not to be employed. 

The dressings are pads of sterile gauze (not iodoform gauze) applied 
over the opening in the tube. This allows freedom of chest movements of 
the unaffected side and greater degree of cough impulse, thus favoring the 
expansion of the compressed lung. The child should be allowed to get up 
as soon as possible, and early encouraged to blow through some musical 
instrument, or to make soap bubbles. This plan, coupled with proper tonic, 
dietetic, and hygienic treatment, should give good results. 



DISEASES OF THE LUNGS AND PLEURA. 361 

In long standing or neglected cases of empyema in which there are 
many and firm adhesions with or without collapse of the lung, Lloyd advo- 
cates digitally breaking up all the adhesions and allowing the lung on the 
opposite side to inflate the collapsed lung after the anesthetic has been 
temporarily stopped. 

Pneumothorax. 

Pneumothorax or air in the thoracic cavity is an exceedingly rare condition 
in early life. It is usually tuberculous, but may also result from traumatism, 
foreign bodies in the bronchi, rupture of a bronchiectatic cavity, pulmonary 
abscess, empyema, or caseating lymph nodes. Cases have also been reported 
following pertussis, diphtheritic and laryngeal stenosis. 

Symptomatology. — The symptoms begin very abruptly ; dyspnea, cyanosis, 
thoracic pain, and a rapid thready pulse being the cardinal symptoms. Percus- 
sion elicits a tympanitic or hyperresonant note, as a rule, but a dull note is occa- 
sionally obtained if the pleura is disturbed. Vocal fremitus is absent. Voice 
sounds are distant, and metallic succession may be obtained over the tympanitic 
area. 

If both air and fluid are present (hydropneumothorax), the viscera may be 
displaced from their normal relations. One of us recently observed such a case 
following attempts to relieve a stricture of the esophagus. We have observed 
sacculated pneumothorax resulting from a pyothorax in which the onset was 
gradual and the symptoms proportionately less intense. 

Prognosis. — This is, as a rale, unfavorable, owing to the severity of the 
underlying causes. 

Treatment. — Absolute rest to body in the prone or semirecumbent position 
must be insisted upon. Stimulation and chest strapping are indicated. The recent 
experiments with positive pressure and the Sauerbruch box for intrathoracic 
operations offer some hope for surgical procedure in these cases. 

Pulmonary Abscess. 

This is a rare condition resulting from the invasion of pyogenic bacteria, fol- 
lowing aspirated foreign bodies in the lung, pneumonia, pulmonary emboli, or 
caseating lymph nodes. 

Symptomatology. — The symptoms develop slowly, following what appears 
to be a protracted convalescence. Often they are not distinctive in character. 
The emaciation is progressive, the temperature, if followed closely, shows a septic 
curve. Profuse sour sweating is the rule. If combined with the above descrip- 
tion we have thick purulent sputum containing leukocytes and elastic fibers, and 
if on blood examination a marked leukocytosis (50,000 to 60.000 per cm.) is 
found, abscess of the lung should be considered and a diagnosis made by exclud- 
ing tuberculosis, encapsulated empyema and gangrene of the lung. In selected 
cases surgical treatment may be of avail. The V-ray should be employed for 
corroboration. 

Gangrene of the Lung. 

Pulmonary gangrene is a rare condition in children, resulting from pyogenic 
bacteria infecting a necrotic portion of the lung. It is a secondary condition 
following pneumonia, the infectious diseases, bronchiectasis, the aspiration of 
foreign bodies, or gangrenous stomatitis. The diagnosis is more often made at 
necropsy than during life. 

Diagnosis. — This is founded upon the putrid expectoration of a dirty green- 
ish color, which on examination is found to contain shreds of pulmonary tissue. 
The child's breath is almost always offensive. There is progressive emaciation, 
prostration and an irregular temperature. The cough is somewhat paroxysmal, 
followed by the expectoration of a good quantity of the characteristic sputum. 



36 2 



DISEASES OF CHILDREN. 



Even young children will expectorate or vomit who are suffering with pulmonary 
gangrene. Following the evacuation of the pus we may be able to obtain the 
cavernous signs indicating a cavity. Hemoptysis sometimes follows after a severe 
attack of coughing. 

Course and Prognosis. — The prognosis is invariably grave. Careful super- 
vision and aerotherapy may so far improve the patient's general condition that 
surgical measures may be justifiably at- 
tempted with the chance of a permanent 
cure. 

Treatment. — Until operative measures 
can be instituted, forced feeding, stimula- 
tion and cod-liver oil should be used. In- 
halations of the compound tincture of 
benzoin, turpentine, or the oil of eucalyp- 
tus will mitigate the foul odor. 

Bronchiectasis. 

This disease results from a weakening 
of the bronchial wall following a number 
of pulmonary conditions, the most impor- 
tant of which are interstitial pneumonia, 
chronic bronchitis, emphysema, pulmonary 
collapse, tuberculosis, and foreign bodies. 
The dilatations are cylindrical or sacculated 
or small and diffuse, and always contain a 
large number of bacteria. Measles, whoop- 
ing cough and influenza represent predispos- 
ing causes. 

Symptomatology. — Added to the symp- 
toms of the underlying disease, or during 
convalescence therefrom, the patient begins 
to expectorate a quantity of mucopurulent 
sputum. The cough is paroxysmal, and 
may be induced by changing the position of 
the patient from the diseased to the normal 
side. The collected sputum has a disagree- 
able odor, is thin, grayish-brown, and sep- 
arates into a frothy, a watery, and a 
granular layer. The fever is moderate, as 
a rule, although exacerbations in which 
may occur high fever, night-sweats, diar- 
rhea and pulmonary hemorrhage, are not 
uncommon. 

Physical Signs. — In a typical case, 
with a well-developed cavity, cavernous or amphoric breathing with diminished 
vocal resonance may be heard over the affected area. After a free expectoration, 
numerous coarse mucous rales with bronchophony may be obtained. On percus- 
sion a tympanitic note is heard. Other evidences may be found in the clubbed 
fingers, emphysematous areas, or the development of a pulmonary gangrene. 

Diagnosis. — The paroxysmal coughing occurring on change of position, with 
large quantities of expectoration, with the general condition not proportionately 
affected, tend to differentiate it from the more acute condition of pulmonary gan- 
grene which causes marked prostration and shows in the sputum portions of lung 
parenchyma. The needle may distinguish it from abscess, and the sputum exam- 
ination from pulmonary tuberculosis. The X-rays are of little help in this 
condition. Willy Meyer proposes to try insufflation of collargol into the depth of 
the tracha? and bronchi after a very thorough expectoration, and in this way 
enable the radiologist to map out the involved areas. 




Fig. 106— Shaded area over a 
bronchiectatic cavity. 



DISEASES OF THE LUNGS AND PLEURA. 363 

Course and Prognosis. — The disease may extend over many months or 
years, but complete recovery is extremely rare. Complications are easily acquired 
leading to a fatal result. 

Treatment. — This should be directed toward conserving the strength of the 
patient by the use of nourishing food and a protracted sojourn and life in the 
mountains or at the sea-shore. The inhalation of the volatile balsams, such as 
benzoin, turpentine, or eucalyptus, are indicated. 

Quincke's postural method, raising the foot of the bed; or the method of 
expiratory compression may be used if the cavity does not thoroughly empty itself 
after coughing. Terpene hydrate or guaiacol carbonate may be administered 
internally. Resection of the ribs, collapse, and drainage of the cavity has been 
attempted, but thus far with indifferent results. Artificial pneumothorax has 
been recently tried. From this measure improvement only can be expected. 
Pneumectomy, or the extirpation of the diseased lobe or lobes, while a very 
serious operation, offers the only hope of a successful cure. 

Foreign Bodies in the Respiratory Tract. 

Various objects may find their way into the larynx, trachea, or even into the 
bronchi by accidental inspiration at the time of coughing or laughing when the 
foreign body is in the mouth. Among the objects we have collected are an 
upholsterer's tack, the glass eye of a doll, fish bones, and a carrib bean. 

Symptomatology. — A sudden violent fit of coughing or choking follows the 
aspiration and cyanosis results ; extraordinary efforts are made by the child to 
breathe. Occasionally the paroxysm is so slight as to be mistaken for whooping 
cough or croup. If the object is sharp, as a fish bone, for example, there is some 
local irritation or later symptoms of obstruction. The attacks may be followed 
by periods of comparative quiet and rest. If the object is small and smooth, and 
is not coughed up at once, it will eventually find its way into a bronchus. It 
passes usually, owing to its position, into the right bronchus. 

Diagnosis. — If a history is obtained and the symptoms of the initial suffo- 
cative attack are well described, the diagnosis may be made, without the knowl- 
edge that an object has been aspirated. When the symptoms come on gradually, 
the diagnosis may be entirely obscured. However, a bronchiectatic cavity, pul- 
monary collapse, or abscesses should lead to a careful investigation with this 
diagnosis in mind. An X-ray examination may materially aid in clearing up a 
suspected case. 

Treatment. — The finger or the laryngeal forceps may succeed in removing 
a recently aspirated object. If unsuccessful, tracheotomy may be necessary in 
cases which would otherwise suffocate, surgical measures for the removal of the 
foreign body being later employed. 

Direct laryngobronchioscopy (see p. 342) has rendered excellent service in 
the removal of objects from the bronchi. The fluoroscope has also successfully 
directed the surgeon in locating and extracting the foreign body. 

Subphrenic Abscess. 

This consists of an accumulation of pus between the liver and the diaphragm 
on the right side, or between the stomach, spleen, and diaphragm on the left side. 
Downward extension of an empyema through the diaphragm is the usual cause in 
children, although it may result from intraabdominal disease. It may also com- 
plicate conditions such an appendicitis and acute pneumonia of the septic type. 
Empyema is most often diagnosticated and the real condition discovered at opera- 
tion. Rarely the abscess contains air. and pyopneumothorax may be suspected. 

Symptomatology. — Beside the symptoms of the primary condition there may 
be added chills, rapid pulse, remittent fever, localized pain and tenderness, nausea 
and vomiting, with impeded respirations. In a case seen by one of us there was 
also a moderate amount of bulging, and the liver was displaced by the pus. 

Treatment. — Prompt surgical intervention with the establishment of drain- 
age is imperative. The prognosis should be guarded. 



SECTION VIII. 
DISEASES OF THE CIRCULATORY SYSTEM. 



CHAPTEE XXV. 
DISEASES OF THE HEART. 

Two factors in early life contribute to the vigor of the circulation: 
(1) The strength of the heart muscle itself and the readiness with which 
it hypertrophies when compensation is required. (2) The elasticity of the 
arteries. It is frequently not appreciated how important a function the 




Fig. 107. — Radiograph of normal heart. 

arteries play in the round of the circulation. By their tonicity they aid 
the heart in propelling the blood in a constant stream to the various parts 
of the body. If the arteries are healthy and elastic great help is thus 
afforded the heart in the equable distribution of the blood. Even a crippled 

364 



DISEASES OF THE HEART. 365 

heart acts to much better advantage when the arteries can perform their 
full share in the work of the circulation. Thus in early life, when the 
arteries are nearly always in a sound condition, a lesion of the heart may 
produce comparatively little discomfort, especially when compensatory 
hypertrophy is satisfactory, as is very apt to be the case. When, however, 
middle age approaches and a stiffening of the arteries ensues from athe- 
romatous change, we will soon encounter dyspnea and other evidences of a 
failing circulation. 

The blood pressure itself, as registered by the sphygmomanometer, is 
lower in children than in adults. The normal limits of systolic pressure at 
different ages have been given as follows: 

Infants, 75 to 90 mm. 

Children, 90 to 110 mm. 

Young adults, 100 to 130 mm. 

Older adults, 110 to 145 mm. 

In a series of observations made by us at the Postgraduate Hospital 
with the Stanton sphygmomanometer, the above figures were confirmed, and 
observations were made in diseased conditions; but while of interest, it 
was found that blood pressure estimations were not of much practical value 
in early life. 

The Heart. 

The infant has relatively a larger heart than older children and adults, 
and it assumes a more horizontal position from a greater breadth. The 
apex beat in early life is in the fifth intercostal space and is sometimes a 
little external to the mammary line. With increasing age the apex beat 
deflects a little downward and inward, reaching well within the mammary 
line. 

Enlargement of the heart may be noted by the position of the apex 
beat and by an increased area of dullness on light percussion. The space 
for such percussion is situated between two parallel lines, one line running 
through the middle of the sternum and the other through the left nipple. 
Absolute heart dullness will be noted in a small triangle formed by the left 
border of the sternum, the lower border of the fourth rib and a line running 
from the fourth rib just within the mammary line to the third costal carti- 
lage near the left border of the sternum. The dullness caused by the left- 
ventricle will be marked out by percussing inward from the mammary line 
over the second, third, fourth, and fifth ribs; that caused by the right ven- 
tricle will be located by percussing over the fourth interspace beginning 
outside the right sternal line and percussing toward the sternum. Dullness 



366 DISEASES OF CHILDREN. 

caused by the apex may be noted by percussing from the middle of the 
sternum along the fifth interspace to the anterior axillary line. 

The heart beats with great rapidity in early life and it is often puz- 
zling to determine accurately the character of the sounds heard. The pul- 
monic second sound is accentuated throughout the early years and a certain 
arythmia is often observed. The pulse is frequently irregular and its 
rapidity is greatly influenced by any disturbing conditions, such as crying; 
it also varies much during waking and sleeping hours. The following may 
be considered as a fair general average : 

Newborn, 120 to 140. 

First year, 110 

Second year, 100 

Fifth to eighth year, 90 

Congenital Heart Disease. 

(Cyanosis; Blue Disease.) 

New-born infants sometimes exhibit a persistent blueness, due to mal- 
formation of the heart. This defect usually takes the form of deficiency in 
the interauricular and interventricular septa. The great vessels may like- 
wise be involved in the malformation, especially the pulmonary artery. Dr. 
J. L. Smith found in over half of the 162 cases he examined at autopsy that 
the pulmonary artery was absent, rudimentary, impervious, or partially 
obstructed. He also found the following lesions : Eight auriculoventricular 
orifice impervious or contracted; orifice of the pulmonary artery and the 
right auriculoventricular aperture impervious or contracted ; right ventricle 
divided into two cavities by a supernumerary septum ; one auricle and one 
ventricle; a single auriculoventricular opening, with interauricular and 
interventricular septa incomplete ; mitral orifice closed or contracted ; aorta 
absent, rudimentary, impervious, or partially obstructed; aortic orifice and 
left auriculoventricular orifice impervious or contracted; aorta and pul- 
monary artery transposed, the vena cava entering the left auricle; pulmo- 
nary veins opening into the right auricle or into the vena cava or azygos 
veins ; aorta impervious or contracted above its point of union with the 
ductus arteriosus ; the pulmonary artery wholly or in part supplying blood 
to the descending aorta through the ductus arteriosus. 

It is obvious that with any of these grave central lesions not only the 
peripheral circulation, but the nutrition as well must suffer. The blood is 
deficient in oxygen and has an excess of carbon dioxid. The blueness is 
most pronounced in the prominent parts of the face, such as the eye-brows, 
cheek-bones, nose, and lips. The hands and fingers are also prominently 



DISEASES OF THE HEART. 367 

affected. The color varies from a light to a very deep purple, the discolor- 
ation being aggravated by crying or other disturbing influence. 

While the infants at birth may be well developed, there are soon evi- 
dences of failure of nutrition, and they are very susceptible to intercurrent 
diseases. The action of the heart is rapid and tumultuous, and the respira- 
tion is correspondingly disturbed. Various bruits are heard upon auscul- 
tation of the heart, especially a systolic murmur at the base. The right 
heart is usually enlarged. The infants suffer from lack of sufficient animal 
heat, and because of this and pulmonary congestion they easily contract 
pneumonia. They are apt to be carried off by any intercurrent disease, 
and whooping-cough is especially badly borne. In a majority of cases of 
congenital heart lesion, the general blueness is noted immediately or very 
shortly after birth. In a minority of cases, however, the lividity is not 
noticeable for an interval of time, varying from a few weeks to a few 
months after birth. A few cases have been reported where even a few years 
have elapsed before the blueness has become marked. The defect occurs 
more frequently in male than in female infants. While this peculiarity has 
been noted by most observers no explanation can be given of it. Most cases 
do not survive the first year, but occasionally a case will live through infancy 
and childhood. It is very rare to find one surviving adolescence. Those 
that survive infancy present a stunted appearance, although well formed at 
birth. The chest becomes deformed, with a projecting sternum, and the 
fingers and toes bulbous from the sluggish circulation. Anasarca may 
occur toward the end of life, to be noted in the face or ankles, and rarely in 
other parts of the body. Death may take place from exhaustion, during a 
paroxysm of dyspnea, from convulsions or from a feeble resisting power in 
some intercurrent disease. 

Diagnosis. — In order to distinguish congenital from acquired heart 
disease, it may be borne in mind that the latter is rarely seen in infancy, 
especially early infancy. The congenital type shows early and there is 
general blueness, marked dyspnea, defective development with later bulbous 
fingers and toes. There is likewise no appearance or history of rheumatism 
or acute endocarditis. The commonest bruit is the loud murmur at the 
base. 

Treatment. — A general hygienic oversight is the most that can be 
accomplished. The infants must be kept warm and carefully fed. If the 
blueness and dyspnea become extreme, oxygen may give temporary relief. 
Small doses of digitalis may be occasionally given as an aid to the circula- 
tion. 



368 DISEASES OF CHILDREN. 

Acute Endocarditis. 

Endocarditis is an inflammation of the endocardium which especially 
affects the lining membrane of the valves and the parts contiguous to them. 

Etiology. — The commonest cause is the virus of rheumatic fever, and, 
in some cases, it may be the first and even the only manifestation of this 
disease. Usually, however, it is preceded by several attacks of the mild 
form of rheumatism seen in early life. It is also not infrequently seen in 
connection with chorea and repeated attacks of tonsillitis. The latter dis- 
ease may alone be responsible for endocarditis or it may be associated with 
rheumatism, the two conditions either preceding or following the heart 
attack. Clinical experience forces the belief that certain forms of tonsillitis, 
rheumatism, chorea and endocarditis are frequently manifestations of the 
same underlying pathological condition. Any infectious disease may attack 
the endocardium, especially scarlet fever, cerebrospinal fever, diphtheria, and 
typhoid fever. In some cases influenza may act as a cause. Any of the 
septic conditions are also liable to provoke inflammation in the endocardium. 

Pathology. — In fetal life the right side of the heart is attacked, but 
this rarely occurs after birth, when the left side is almost exclusively 
affected. The valves are most frequently the seat of the inflammation, the 
mitral valve being oftenest affected and next the aortic and occasionally the 
pulmonary valves. The affected valve is thickened from a proliferation of 
connective-tissue cells and may be covered by small deposits of fibrin, espe- 
cially around the margins. Small thrombi and vegetations may also be 
present, which are liable to separate and be carried into the general circu- 
lation. In this manner secondary infections are liable to take place in 
various vital organs. Leakage of the valve may be caused by contractions 
of the chordae tendinse or ulceration with perforation of the valve. Strep- 
tococci or the staphylococcus pyogenes are the bacteria that most frequently 
infect and inflame the endocardium and rarely pneumococci, either from 
the presence of the bacteria or their toxins in the blood stream. The tonsils 
are also considered to be one of the primary seats of many of the bacteria 
that thus affect the heart, and cases of endocarditis follow tonsillitis. There 
is usually some inflammation of the myocardium coexisting with endocar- 
ditis which causes a softening of the heart muscle and consequent dilatation. 
This accounts for some of the valvular insufficiency seen during and after 
the attack. 

Symptomatology. — The symptoms are often very obscure, being 
masked by the original infectious disease that is the cause of the heart 
lesion. On this account the heart must be frequently and carefully exam- 
ined during attacks of rheumatism, scarlet fever, diphtheria, tonsillitis, 
chorea, and in any septic condition. A soft, systolic murmur is usually 



DISEASES OF THE HEART. 369 

heard, most noticeable at the apex and transmitted toward the axillary 
region. There may be slight dyspnea and evidences of some dilatation, 
especially if the child cannot be kept quiet. An irregular fever with in- 
creased respiration and pulse rate will also be noted. Young children 
rarely complain of pain or discomfort in the cardiac region, but older chil- 
dren may describe a feeling of constriction, slight pain, or palpitation. 

Septic Endocarditis. — The symptoms of this form of endocarditis, 
otherwise known as malignant or ulcerative endocarditis, are much more 
urgent and marked. There are chills with high, irregular fever and sweats. 
There is likewise great prostration, with delirium and even coma. There 
are no characteristic symptoms referable to the heart beside a murmur and 
possibly more marked dyspnea than in the ordinary attacks. Ulcerations 
take place on the valves, and septic emboli are liable to be detached and 
carried to the lungs, kidneys, brain, or other vital organs. A typical sign 
consists of purpuric spots or petechia? which soon appear on the neck, 
chest, abdomen, or extremities. This form of endocarditis may occur in 
any septic condition, when various bacteria may be found in the blood and 
thus the cause of the heart lesion demonstrated. Fortunately, septic or 
malignant endocarditis is very rare in early life as it is practically a fatal 
disease. 

Diagnosis. — A soft, systolic murmur at the apex that develops during 
an illness, with irregularity of the heart's action and some dilatation is sus- 
picious of endocarditis. The murmur is transmitted toward the axilla and 
is usually accompanied by fever and increased rapidity of the pulse. A 
purring thrill may also be present and an increased pulsation over the area 
of the heart's action. Hemic or myocardial murmurs are inconstant, are 
noted especially at the base or over the pulmonic area and are not trans- 
mitted. These murmurs are usually systolic, but there is no evidence of 
dilatation or marked cardiac disturbance and there is absence of fever and 
other signs of acute illness. Pericarditis is recognized by the friction 
sound, dullness on percussion, or absence of distinct apex beat when effusion 
is present. 

Prognosis. — The prognosis is good as regards life, except in the septic 
or ulcerative form. The outlook is not so good with reference to the 
future crippling of the heart from thickening or retraction of the valves. 
Cases have been reported, however, in which no permanent lesion has fol- 
lowed endocarditis, especially when the disease has been early recognized and 
the child kept quiet. Most of the cases, especially those of rheumatic 
origin, are followed by some permanent lesion. 
24 



370 DISEASES OF CHILDREN. 

Treatment. — Eest in bed in a recumbent position is most important 
during the acute stage. Any exertion that results in dilatation of the soft- 
ened heart muscle will cause insufficiency. An ice-bag may be placed over 
the heart, and the tumultuous heart action may also be controlled by small, 
non-narcotic doses of opium. The latter drug will also tend to allay rest- 
lessness and thus render it easier to keep the child quiet. Grains 1/50 to 
1/30 of morphin sulphate may thus do good service. If the heart's action 
is weak, with evidences of dilatation, strychnia or digitalis will be indicated. 
When any joints are involved or in the face of a rheumatic history, the 
treatment should be with sodium salicylate in double or treble dosage 
through the rectum. Aspirin or the alkalies by the mouth in milder cases. 

In cases in which the kidney secretion is deficient, caffein soda ben- 
zoate, one to two grain doses, will be beneficial. The effort should be to 
induce a regular pulse under 100 in the child. 

Carbonic acid and Nauheim baths with graduated resistant exercises 
are to be used throughout convalescence. 

The bowels must be kept open, and a light, low protein diet given. 
In cases having a weak or dilated heart, with irregular pulse, it may be 
necessary to keep the child quiet in bed for many weeks or until a distinct 
improvement is noted. 

In septic endocarditis blood cultures should be made twice a week in 
the effort of finding the organism. (This requires expert and specialized 
laboratory technic.) When the organism is found a homologous vaccine 
can be made and used according to Wright's method. Becent reports 
(Thompson, et al.) have been extremely encouraging in this heretofore fatal 
disease. 

Myocarditis. 

Myocarditis is an inflammation of the heart muscle followed by soften- 
ing and degeneration. 

Etiology. — i The toxins produced by the bacteria of the various infec- 
tious diseases may cause an inflammation of the heart muscle. Diphtheria 
and scarlet fever are the diseases most often responsible for thus attacking 
the heart. 

Pathology. — In some cases there is a cloudy swelling and a granular 
and hyalin degeneration of the muscle fibers, and in others there will be 
a fatty degeneration. If the latter is extensive, a cut section will show a 
yellowish appearance of the heart muscle. There may also be a small, 
round-celled infiltration between the muscular fibers. 

Symptomatology. — The milder forms of the disease may show no 
symptoms referable to the heart. In severer attacks there will be dyspnea, 



DISEASES OF THE HEART. 371 

faint feelings, and a rapid, irregular pulse. It is difficult to locate the 
position of the apex beat, and there will be an increased area of cardiac dull- 
ness due to dilatation. The grave cases show general pallor, with cyanosis 
of the lips and finger-tips, and a sudden collapse from heart failure may be 
the terminal condition. The symptoms are liable to be masked, as in endo- 
carditis, by the primary infectious disease. Vomiting, occurring in con- 
nection with a weak, irregular pulse in diphtheria, is usually of serious 
import. A pulse becoming slow in an infectious disease, especially diph- 
theria, after having been rapid, is of grave significance. We have seen the 
pulse drop from 150 to 50 and 40, and, in one case, it reached 25 in diph- 
theria with a complicating myocarditis. Death nearly always ensues in 
cases having a very slow pulse. In chronic and severe valvular disease, a 
lack of tone in the heart muscle, due to a slow and progressive myocarditis, 
will be shown by failure of compensation with resulting dyspnea, congestion 
and enlargement of the viscera, and dropsies. 

Diagnosis. — The diagnosis rests upon a weak and irregular action of 
the heart, a feeble first sound, and accentuation of the pulmonic second 
sound and difficulty in locating the apex beat. In addition to these local 
signs there will be faintness, pallor, and general prostration. 

Treatment. — The heart must be supported by absolute rest in the 
recumbent position. Sudden dilatation and weakness may be combated 
by hypodermatic injections of small doses of morphin and atropin. Sul- 
phate of strychnin is useful in sustaining the heart's action. Prolonged rest 
and avoidance of exertion must be insisted upon during convalescence. 



CHAPTER XXVI. 
CHRONIC VALVULAR DISEASE. 

Physicians are often called upon to treat cases with valvular diseases 
of the heart when it is impossible to find out the beginning of the trouble. 
The patient may be unable to give a history either of rheumatism or endo- 
carditis, but seeks advice for dyspnea, swelling of the extremities, or other 
symptoms of failing circulation. We believe that a large proportion of the 
cases of valvular disease in the adult started during childhood, the first 
beginning of the trouble, which is the period for hopeful treatment, not 
having been recognized. The nature of the rheumatism that attacks chil- 
dren is often obscure, and several attacks of wandering or so-called " grow- 
ing pains " may be overlooked. While the heart may be the first structure 
attacked by rheumatism, this is not the common order of events. In most 
of our histories of valvular disease in children the cardiac affection seemed to 
come on after several attacks of rheumatism. Great care should be exer- 
cised in making an early diagnosis, and vigorous measures be taken to 
combat these first manifestations of rheumatism, fearful that, although the 
heart may escape the first mild attacks, it maj r suddenly and unexpectedly 
become affected by an equally light manifestation of the disease. 

When endocarditis ensues, as previously noted, the symptoms are often 
very obscure. Palpitation, slight pain, and breathlessness, with a dry 
cough, may not be particularly noticed by parents. In all suspicious cases 
we would strongly emphasize the importance of a careful examination of 
the heart on the part of the physician, a stethoscope being used. Just at 
this juncture rest is indicated above all things. If this is not procured, the 
delicate, softened heart muscle quickly undergoes dilatation, followed by 
permanent damage to the valve. Dilatation takes place very readily in the 
young subject. If it is true that endocarditis need not always nor neces- 
sarily eventuate in permanent valvular disease, and this seems to be gen- 
erally believed, we may certainly aid such a result by doing all in our power 
to avoid dilatation. By recognizing the endocarditis at the beginning and 
keeping the child as quiet as possible, we may thus seek to avoid dilatation 
and consequent crippling of the valves. Even after the immediate symp- 
toms of endocarditis have passed, children are too often allowed to take 
part in all kinds of vigorous exercises as if nothing amiss had happened. 

In many cases children suffering from chronic valvular disease show 
few symptoms of circulatory disturbance. This is explained by a more or 

372 



CHU0X1C VALVULAR DISEASE. 



373 



less perfect compensation which generally and completely ensues from hyper- 
trophy, and there may thus be no positive sign until years later that serious 
damage has been effected. The peripheral arteries are also healthy and 
elastic at this time, which fact, as previously noted, greatly facilitates the 
work of the heart As the patients grow older, and vascular degenerations 
begin, and the limit of compensatory hypertrophy is reached, marked 
dyspnea and other symptoms of a failing circulation will be noted. We 

have seen children after a severe, 
neglected case of endocarditis, or 
after several attacks, suffer in this 
way. but in a large number of cases 
the principal evidence of valvular 
disease will be shown by general un- 
derdevelopment, malnutrition, and 
anemia. 

The extent of the heart lesion 
cannot be estimated by the relative 
loudness or softness of the murmur. 
We must estimate the amount of 
crippling caused by valvular defect 
by two factors in our examination of 
the heart : first, the position of the 
apex beat, and second, a marked ac- 
centuation of the pulmonic second 
sound. If there is no hypertrophy 
of any part of the heart muscle, it 
is not probable that any real valvular 
defect is present. While in early 
life the pulmonic second sound is 
relatively louder than in later years, 
if it is very markedly accentuated 
there is evidently an interference to 
the passage of the blood through the 
lungs, due to some valvular lesion. 
In early years the mitral valve alone is most frequently the seat of 
chronic disease; next a combination of mitral and aortic lesions is found, 
and very rarely the aortic valve alone is affected. This is explained by the 
fact that the mitral valve is most often attacked by rheumatism, while 
atheroma, gout, and old age are the commonest causes of aortic disease. 

Location of tlie Valves. — -The mitral valve is situated at a point where 
the upper border of the left fourth costal cartilage joins the left border of 




Pig. 108. — Chronic endocarditis, 
cardiac hypertrophy, enlargement of 
liver with ascites. 



374 DISEASES OF CHILDREN. 

the sternum. The aortic valves are placed behind the sternum at the junc- 
tion of its left margin with the lower edge of the third left costal cartilage. 
The pulmonary valves are located at the junction of the left border of the 
sternum and the third left costal cartilage. The tricuspid valves are found 
behind the middle of the sternum on the level of the line connecting the 
fourth costosternal cartilages. The valves of the left heart are situated 
deeper than, and behind those of the right heart. Organic defects in the 
valves give rise to adventitious sounds known as organic cardiac murmurs, 
produced by the passage of the blood over or through the valves affected. 
These murmurs are not heard with maximum intensity directly over the 
valve affected, but near it, and are transmitted in the direction of the blood 
current. The following are the locations of the loudest sounds in the 
valves when diseased : mitral murmurs loudest at the apex ; aortic murmurs 
loudest at second right intercostal space ; tricuspid murmurs loudest at the 
ensiform cartilage. 

Mitral Regurgitation. 

Any insufficiency or leak in the mitral valves will be followed by regur- 
gitation of blood during the systole. There will then ensue, first, a dilata- 
tion and hypertrophy of the left auricle ; next, hypertrophy of the left 
ventricle required by the extra work thrown upon it in propelling the blood 
through the aortic valves, and, finally, an hypertrophy of the right ventricle 
which has difficulty in forcing the blood through the lungs to be emptied 
in the left auricle. 

A physical examination will show general evidence of enlargement. A 
visible impulse of the heart's action can usually be detected and the apex 
beat is felt below and to the left, or outside its usual location. On percus- 
sion, the area of dullness will be increased to the left and below, from en- 
largement of the left auricle and ventricle. On auscultation a systolic 
murmur is heard, having a blowing and rarely a musical character. The 
murmur is transmitted from the apex across the axilla to the inferior angle 
of the left scapula. The murmur is sometimes heard in children at the 
latter location behind, plainer than at the apex at front. An accentuation 
of the pulmonic second sound is usually marked. 

Mitral Obstruction. 

A presystolic or auriculoventricular sound is produced by some inter- 
ference with the normal and easy passage of blood through the auriculoven- 
tricular septum or valve. The murmur is rough and blubbering in quality, 
beginning at the end of diastole and ending abruptly with systole. One of 



CHRONIC VALVULAR DISEASE. 375 

the most characteristic points about this murmur is its abrupt termination. 
This quick stop of the abnormal bruit is very different from the gradual 
ending of mitral regurgitation. The obstruction in the valve leads to 
hypertrophy of the- left auricle and finally to enlargement of the right ven- 
tricle, which has more work to do in flushing the blood through the lungs. 
The left ventricle is not hypertrophied, and accordingly the apex beat will 
appear in about its normal location. Any enlargement will be noted by an 
increased area of dullness to the right of the sternum. A purring thrill ia 
usually felt by placing the hand over the heart. On auscultation a blubber- 
ing murmur is heard only in the region of the apex and is not transmitted. 
It is likewise somewhat variable and may be hardly audible during repose, 
and yet very evident when the patient is required to make some exertion. 
The pulmonic second sound is always accentuated. 

Chapin has reported a series of forty cases in which children giving 
evidence of mitral obstruction were kept under observation for different in- 
tervals of time from a few weeks to several years. The commonest symptoms 
noted were varying degrees of pain referred to the region of the heart and 
dyspnea on exertion. Thirty-one of the cases gave evidence of simple mitral 
obstruction, while in nine cases there were combined murmurs. Most of 
the cases were preceded by a rheumatic manifestation that was mild even 
for children, and he concludes that while mitral stenosis is not independent 
of rheumatism it is apt to be associated with the less pronounced forms 
of it. 

In growing children, especially girls, who are pale, nervous, anemic, 
and troubled with digestive disturbance, an irregular action of the heart 
may produce a rough sound simulating mitral obstruction, which disappears 
under improved conditions. 

Aortic Obstruction. 

This lesion is infrequent in childhood. It is accompanied by a systolic 
murmur heard at the base at the second right interspace and transmitted 
upward. The aortic second sound is somewhat weakened, but there is no 
accentuation of the pulmonic second sound. There is hypertrophy of the 
left ventricle and the apex beat is accordingly pushed downward and out- 
ward. The latter will distinguish this sound from functional or hemic 
murmurs with which it is apt to be confused. 

Aortic Regurgitation. 

This lesion is likewise not very frequently seen in early life. The 
murmur is diastolic, taking the place of the aortic second sound. It is 
rather harsh in character and is transmitted downward over the sternum, 



376 DISEASES OF CHILDREN. 

being heard with greatest intensity at about the fourth cartilage or some- 
times at the lower extremity of the sternum. There is great hypertrophy 
of the left ventricle, and accordingly much displacement of the apex beat 
downward and outward, and the heart usually acts with considerable force. 
The so-called " water-hammer pulse " is typical, consisting of a full, 
arterial wave followed by a sudden fall in the pressure. 

Tricuspid Regurgitation. 

This lesion is very rare and apt to be overlooked. It may be caused 
by disease of the valve itself or secondary to a dilated right ventricle. There 
is a very soft systolic murmur heard over the ensiform cartilage. It is 
distinguished from aortic regurgitation by being systolic instead of diastolic, 
and also by more marked cyanosis, by pulmonary edema, and jugular 
pulsation. 



Prognosis in Valvular Disease. — The immediate prognosis in chil- 
dren, even when the lesion is fairly severe and extensive, is usually good 
for reasons already noted. There is nearly always, however, a more or less 
defective nutrition. There are cases in which slight lesions appear to 
undergo complete recovery, especially when a healthy general growth can 
be accomplished. Eepeated attacks of rheumatism, with the clanger of 
renewed endocarditis, are a grave menace to the heart by upsetting com- 
pensation and increasing existing lesions or forming others. The ultimate 
prognosis is not good in most cases of marked valvular disease with any 
evidences of decompensation, as it is only a question of time when the 
compensation will fail in later life. 

Treatment. — Many cases require no treatment directed to the heart, 
but the general nutrition and growth require careful oversight. Nourish- 
ing, digestible food, with the occasional administration of remedies to build 
up tissues, such as iron and cod-liver oil, are frequently all that are required. 
These cases should not be restricted too much in exercise and amusement. 
All the milder games may be allowed, only avoiding the more violent and. 
competitive sports. Any acute infectious disease and the slightest mani- 
festation of rheumatism must mean extra rest, and anxious care on the part 
of the physician. Any evidence of failing compensation will likewise require 
rest and the administration of heart tonics, especially strychnin and digi- 
talis. Then Nauheim baths and graduated cardiac exercises will be re- 
quired to establish convalescence. In cases of great dyspnea and restless- 
ness small doses of codein by the mouth or minute non-narcotic doses of 
morphin given hypodermatically will often afford relief. 



CHRONIC VALVULAR DISEASE. 377 

Functional Cardiac Disorders. 

The heart in growing children, especially those with a neurotic ten- 
dency, is very prone to functional disorder. Digestive disturbances and 
the anemias are the commonest exciting causes. 

Palpitation of the heart. — This is seen in connection with indiges- 
tion, from the use of improper food or from the abuse of tea, coffee, or con- 
diments. In older children the strain from overstudy or from masturbation, 
especially at the time of adolescence, is a common cause. The heart may 
be unusually slow or rapid in action, but oftener the latter. 

Hemic Murmurs. — These murmurs are not often heard in infants 
and very young children, but are fairly frequent in older children. They 
are invariably systolic and are usually heard at the base. A diastolic mur- 
mur is always organic. The hemic murmurs are heard more distinctly 
over the pulmonary than over the aortic interspace, are inconstant, and are 
not transmitted in the direction of the blood current. They are usually 
accompanied by a venous hum in the jugular and subclavian veins. The 
most reliable differentiation between hemic and organic murmurs consists 
in the enlargement of the heart from compensatory hypertrophy seen in the 
latter. Murmurs, apparently of hemic origin, are sometimes noted in acute 
febrile affections. Dynamic murmurs, due to a faulty action of the heart 
muscle, are sometimes detected after violent exercise and in choreic or 
hysterical children. A cardiorespiratory murmur may be produced by the 
impulse of the heart against some of the pulmonary vesicles at the end of 
a deep inspiration. It is always systolic and is not heard at the end of 
expiration. 

Treatment. — The management of functional heart troubles is princi- 
pally dietetic and hygienic. The digestion must be carefully regulated and 
only nourishing and easily assimilable food be allowed. It may be necessary 
to remove the children from school so that they can be free from nervous 
strain and have more opportunity to get plenty of fresh air and sunlight. 
All the known sources of nervousness must be removed and opportunity 
given for abundance of sleep. Iron and cod-liver oil are the best remedies. 
Small doses of Fowler's solution may also be employed. 



CHAPTEE XXVII. 
DISEASES OF THE PERICARDIUM. 

Pericarditis. 

This is an inflammation of the pericardium secondary to some 
infections disease. 

Etiology. — The most freqnent canse is rheumatic fever. It may also 
occur in connection with the exanthemata, especially scarlet fever, in various 
septic processes, in tuberculosis and pneumonia. Direct injury is rarely a 
cause, and it may spread by continuity from pleurisy. The following bac- 
teria may act as exciting causes — streptococci, staphylococci, the tubercle 
bacillus, the colon bacillus and the pneumococcus. 

Pathology. — We may recognize three varieties — the fibrinous, sero- 
fibrinous and purulent, according to the inflammatory exudate. In the 
first or adhesive form, the pericardium is covered by an exudation of fibro- 
plastic matter which may lead to adhesions between the visceral and parietal 
surfaces. In the serofibrinous form, the pericardial sac contains a serous 
fluid, together with a fibrinous exudation, which produces adhesions on 
absorption of the fluid. The serofibrinous exudation may occasionally 
become purulent, and rarely blood is exuded into the sac. Miliary tubercles 
may infiltrate both the visceral and parietal surfaces in the tuberculous 
form. Permanent adhesions will be produced by the fibrinous exudation 
being replaced by new connective tissue. More or less myocarditis is present 
in connection with pericarditis, the same as in endocarditis. 

Symptomatology. — The subjective symptoms are of such a negative 
character that the disease is often overlooked. As it is usually a secondary 
condition, the original disease is apt to mask the -symptoms that are pres- 
ent and occupy all the attention of the physician. Palpitation of the heart, 
dyspnea, more or less pain in the epigastric region, rapid, irregular pulse, 
and increased respirations are usually present. In severe cases cyanosis 
may be marked. Where pus is present in the effusion, the temperature 
assumes a more remittent curve. 

Physical Signs. — As the rational signs are obscure, the physical signs 
assume great importance in making a diagnosis. In the fibrous form, a 
superficial friction sound, synchronous with the beat of the heart, may be 
detected. It may be heard on systole alone, or with both systole and 
diastole. It is usually more distinct at the base, but it may also be heard 
toward the apex, especially at the onset of the disease, and is not transmitted. 

378 



DISEASES OF THE PERICARDIUM. 379 

At first, the sound may have a crepitant quality, but later assumes a coarser, 
rubbing, or rasping character. A friction fremitus may be felt over the 
region in which the friction rub is localized by auscultation. 

In the serous form there may be some bulging at the precordial region, 
depending upon the amount of the effusion. From one to two nuidounces 
must be present in the pericardial sac in order to produce marked signs. 
The apex beat is not distinct, being pushed upward and to the left. Where 
there is extensive effusion, the apex beat may be lost. There will be an 
increased area of precordial dullness over the distended sac. It may extend 
on the left outside the mammary line from the seventh rib up to the first rib, 
and from a little to the right of the sternum down to the liver. As in pleural 
effusions, there will be a slight resistance to the finger on percussing. On 
auscultation the heart sounds are muffled or feebly heard, and the apex is 
located with difficulty, if at all. As the fluid is absorbed the friction rub 
will again be noted and the valvular sounds become more distinct. 

Diagnosis. — This must be made by a careful examination of the heart 
in reference to the physical signs just noted. In endocarditis the apex can 
be located and the soft, blowing murmur is transmitted. Acute dilatation 
of the heart and hypertrophy will show an enlargement and increased 
area of dullness, but there will be no friction rub nor signs of effusion, and 
the previous history will help to throw light on the case. A left pleural 
effusion, with or without pericardial effusion, may raise a difficult point in 
diagnosis. The flatness from the pleural effusion will not extend over the 
heart and sternum if there is -no pericardial effusion, but, if both are present, 
the extensive dullness and feeble or absent heart sounds will afford a 
probable diagnosis. 

Prognosis. — The immediate outlook is good except in the septic and 
purulent forms of the disease. The heart may, however, be permanently 
crippled in the case of extensive adhesions. 

Treatment. — The child must be kept perfectly quiet in the recumbent 
position as in all other forms of acute heart trouble, and milk or other 
bland food given. Tumultuous action may be controlled by an ice-bag over 
the heart. Small doses of morphin or codein may be employed to quiet and 
strengthen the heart's action, to control pain, and relieve restlessness. If 
the heart is weak and unsteady, strychnia, caffein, or alcohol may be em- 
ployed. Where effusion is extensive enough to seriously embarrass the 
action of the heart, aspiration may be considered. We have seen a case of 
sudden death, however, due to a slight puncture of the heart muscle where 
this operation was employed. Rheumatism if present, or the original 
causative disease, must be treated in connection with the measures aimed at 
the pericarditis. 



380 DISEASES OF CHILDREN. 

Instruments of Precision as Aids in Diagnosis of Cardiac Conditons. 

There have been no startling advances in our methods of physical 
diagnosis since the days of Skoda and his pupils, and we are only now, 
through the use of scientific instruments, adding valuable record findings 
to those of the unaided senses. 

The use of the polygraph and cardiograph have proved of great value 
in correlating physiologic and clinical data, and give records which are 
true for all time, and only require correct interpretation. These records 
have stimulated closer study of the heart and the circulation, so that the 
anatomist, physiologist, pathologist and clinician have all profited thereby 
and developed newer conceptions of the intricate cardiac mechanism. 

With these instruments it can be shown definitely whether the cardiac 
rhythm is normal; if normal, whether the arrhythmia is due to respiration 
or other influences; whether ventricular contraction follows auricular con- 
traction as it should; whether the excitability of the heart is normal. It 
is possible to study the functions of the cardiac muscle, namely, tonicity, 
rhythmicity, contractibility and conductivity. Thus far, the function of 
conductivity is best understood, and we find it disturbed in the usual forms 
of pulse irregularity. A study of the tracings tells whether the irregularity 
is due to heart block, fibrillation of the auricle, or extrasystole, and, if the 
latter, which one of the three varieties of extrasystole is present. 

If the lesion is in the auriculoventricular bundle, and is so extensive 
as to cause complete "blocking " of the stimulus, then ventricular con- 
traction does not follow that of the auricle, as it normally should, resulting 
in what is known as "heart-block." The dissociation between auricle and 
ventricle may be absolutely complete (the auricle beating independently 
of the ventricle and vice versa) or the ventricle may beat to every second, 
third or fourth auricular contraction. 

When making a physical examination of a patient with heart disease, 
perhaps the least important for the patient is the determination of the pre- 
cise valve involved. The examiner should endeavor to determine the exact 
power of the heart to respond, to study the functionating ability of the 
myocardium and obtain data of the cardiac activity. These facts, in con- 
junction with the physical findings as to size, possible dilatation, or organic 
lesion, enable the physician to form a much more precise opinion as to the 
prognosis, while his treatment, at least, is based on scientific facts and can 
be controlled bv further observations. 



SECTION IX. 
DISEASES OF THE BLOOD AND DUCTLESS 

GLANDS. 



CHAPTER XXVIII. 
DISEASES OF THE BLOOD. 

Glossary. 

Corpuscular Elements. 

Erythrocytes red cells. 

Leukocytes white cells. 

Poikilocytosis. . . .variations in shape of red cells 

Normoblast nucleated red cell of normal size. 

Microblast nucleated red cell of small size. 

Megaloblast nucleated red cell of large size. 

Leukocytosis (or hyper leukocytosis) : increase in total number of white cells 

(more than 12.000) usually implies a polynucleosis. 
Leukopenia : decrease in total number of white cells (below 0.000). 
Polynucleosis : relative and absolute increase of the polynuclears. 
Lymphocytosis : relative and absolute increase in lymphocytes. 
Eosinophilia : relative and absolute increase in eosinophiles. 

Blood. 

Blood consists of a clear yellowish fluid, the plasma, in which float the cel- 
lular elements or corpuscles, the red cells giving to blood its characteristic color ; 
the white cells or leukocytes act as phagocytes, and the blood plates are the 
product of degenerating leukocytes. 

Normal blood contains the following number of cells and blood-plates to the 
cubic millimeter. 

Erythrocytes 4,500.000 to 5,000,000 

Leukocytes 7,500 

Tlates 150.000 to 300,000 

The color of blood is due to the presence of hemoglobin, an organic compound 
of iron. When of normal intensity, this color is given as 100 per cent. The color- 
index of a specimen of blood is obtained by dividing the per cent, of hemoglobin 

by the per cent, of red blood-cells. Normally, the color-index is --;■£ —'■'-- =1. 

* 100% r.b.c. 

The specific gravity of blood is highest in the new-born and during the first 
week or two falls to its lowest point. It remains low during the first two years 
of life, averaging 1.050 to 1.055, then gradually increases as puberty is reached. 
In ndults the specific gravity is about 1.051). The specific gravity varies directly 
with the amount of hemoglobin present. 

Red blood-cells (erythrocytes) arc most numerous per cubic millimeter in 
the first twenty-four hours of life. Hay em estimating the number to be 5,900,000. 
This number gradually falls during the days in which the infant loses weight. 
About the seventh day the average number per cubic millimeter is 4,500,000. 
This is the average number of cells throughout childhood. TTayem is also the 
authority for the statement that early ligation of the funis reduces the number 
of red blood-corpuscles about 500.000 per cubic millimeter. 

381 



382 DISEASES OE CHILDREN. 

Trifling causes in infancy and childhood result in marked changes in the 
red blood-corpuscles in number, size, and shape ; hence poikilocytosis and anemia 
are common. 

The red blood-cell is a biconcave disk, non-nucleated, varying greatly in 
diameter, 3.3 micromillimeters to 10.3 micromillimeters having opaque yellowish 
rims and nearly transparent centers. In adults they show a marked tendency to 
cohere by their flat surfaces forming long rows (rouleaux), though in infancy 
this property is much less marked. 

Nucleated red cells are not normally found in infants. In prematures they 
may be found for three or four days. There are three varieties of nucleated red 
cells: (1) Normoblast which resembles a normal red cell in all particulars 
except that it is nucleated; (2) Megaloblast — a large cell 10 micromillimeters 
to 20 micromillimeters in diameter — seen only in severe anemias; (3) Microcyte 
which is smaller than the ordinary red cell ; this form is rare. 

White blood-corpuscles (or leukocytes) vary in size from the size of a 
red cell to two or three times that size. In the fresh state the larger ones present 
ameboid movements if kept at body temperature. In stained specimens the fol- 
lowing forms may be recognized. (1) Polynuclears (or polymorphonuclear neutro- 
philic leukocytes) ; these constitute about two-thirds of all the white corpuscles in 
normal adult blood. In infancy, they occur in about 18 to 40 per cent. Stained 
by Wright's method, the nucleus takes on a deep navy-blue color. The nucleus is 
very irregular in shape, no two being alike. The protoplasm stains pink. The 
average size of these leukocytes is 13.5 micromillimeters. 

(2) Lymphocytes, stained by Wright's method, show a small oval nucleus 
about the size of a red cell and stain deep blue ; around the nucleus is a narrow 
rim of protoplasm which stains a light blue. At birth, the lymphocytes comprise 
about 40 to 60 per cent, of the total number of leukocytes ; lymphocytes vary in 
size from that of a red cell to two or three times this size, and so are named 
large or small. In the large variety, the nucleus may be placed eccentrically or 
indented, and the protoplasmic rim may be much wider than in the small ones. 
The average size of large lymphocytes is 13 micromillimeters; of small ones 10 
micromillimeters. 

(3) Eosinophiles also have polymorphous nuclei of much looser structure 
and larger granules than the polynuclears. With Wright's method the nucleus 
stains a light blue or lilac and the granules a brilliant pink, the protoplasm stain- 
ing a pale blue. The average size of eosinophiles is 12 micromillimeters. 

(4) Mast cells are about twice the size of a red cell, i.e., 15 micromillimeters. 
The nucleus is usually polymorphous. Large granules (staining dark blue or 
almost black) lie over and around the nucleus and along the margins of the cell. 

(5) Myelocytes occur only in pathological conditions. These are bone- 
marrow cells, and are the forerunners of the polynuclear cell. It is a arge 
cell, the average diameter being 15.75 micromillimeters; it differs from the 
large lymphocytes in having granules; it differs from the polynuclears only in 
the shape of its nucleus which is oval and not broken up and which is in close 
contact with the cell wall for a large portion of its extent, i.e., if egg-shaped it 
is placed eccentrically, 

According to Hayem, the number of leukocytes per cubic millimeter during 
the first fortv-eight hours of life averages 18,000; falls to 7,000 for the third 
and fourth days ; and averages 9,000 to 11,000 after the fifth day. The counts of 
Schiff, Orunsky and Rieder run considerably higher than this. The following 
table (by Wile) gives the relative percentage of polynuclears and lymphocytes 
in the blood during the first ten years : 



DISEASES OE THE BLOOD. 383 

Age iii Polynuclear 

years neutrophils Lymphocytes 

1 35% 53% 

2 38% 51% 

3 42% 47% 

4 47% 41% 

5 52% 39% 
8 52% 37% 

7 53% 35% 

8 54% 33% 

9 55% 31% 
10 60% 30% 

Leukocytosis (or hyperleukoeytosis), i.e., an increase in the number of 
white blood-corpuscles per cubic millimeter, is present in the following patho- 
logical conditions: Pneumonia, diphtheria, pertussis, scarlet fever, ^erysipelas, . 
rheumatism, acute rickets, septic and cerebrospinal meningitis, and in pus cases, 
such as appendicitis, peritonitis, empyema, osteomyelitis, and acute abscess. In 
the above conditions the increase of cells is in the polynuclears and is known 
as polynucleosis. Leukocytosis is also physiological ; e.g., in the new-born, after 
exercise, after a cold bath, and after a full meal ; in this latter condition the 
count may be increased 33 J per cent. 

Leukopenia is a state of diminished leukocyte count, and occurs in typhoid, 
measles, influenza, malaria, tuberculous inflammations and gastroenteritis. 

Lymphocytosis is an increase in the number of lymphocytes, and occurs 
in syphilis (congenital), scurvy, and splenic disease. 

Eosixophilia. an increase in the number of eosinophiles. occurs in leukemia, 
chronic skin disease, and in patients infected with intestinal parasites, particu- 
larly trichina. 

Blood-plates (or plaques) are best seen in fresh-blood preparations. They 
are very small, round or oval bodies, about 2 to 3.5 micromillimeters in diameter. 
In a few seconds they lose their rounded form and become spinous, and ultimately 
very thin filaments of fibrin are seen starting from their angular projections. 
Their functions are not known. 

Anemia. 

A decrease in the amount of hemoglobin produces a state known as 
anemia. The decrease may be in the total amount of blood, in the total 
number of corpuscles, or in the coloring matter of the red cells. Alterations 
in the number of leukocytes do occur in anemic states, yet these changes 
cannot be regarded as factors in the process. 

Simple or Secondary Anemia. 

These anemias are more often secondary to some of the severe, acute, 
or constitutional diseases, as gastroenteritis, syphilis, rickets, tuberculosis, 
nephritis, pneumonia, etc. Bad hygienic conditions and unsuitable food 
are often responsible and occasionally fatal. The nurslings of diseased 
mothers are especially liable to anemia. Loss of blood from any cause is 
serious in early life, and the resulting anemia occasionally persists. The 
parasites and the toxemias produce anemias of this type. 



384 DISEASES OF CHILDREN. 

Pathology. — The red blood-corpuscles are diminished in number, 
sometimes decreased to a million and a half or less. The hemoglobin is 
lowered to 30 per cent., but we have not too rarely had an estimation of 10 
to 15 per cent. Irregular forms are seen in the severe types. Leukocytosis 
in our experience is more often observed than absent in early life. 

Symptomatology. — Languor, anorexia, pale or blanched mucous 
membranes and sallowness of the skin is usually present. Constipation is 
the rule. The gastrointestinal tract is early disordered. Later the child 
tires easily and becomes dyspneic on exertion. The extremities are cold. 
The pulse is soft. The heart action is rapid and hemic murmurs are heard 
over the base and in the neck. The sleep is broken, and the temperament 
changes. While there is usually a steady loss of weight, augmentation may 
follow in aggravated cases of edema. 

The spleen and liver may be found to be enlarged or enlarge after 
some weeks of illness. These children are prone to intercurrent affections 
and easily succumb to a pneumonia or gastroenteric infection. 

Differential Diagnosis. — Lymphatic leukemia must be distinguished 
if there is splenic hypertrophy present. The more intense blood picture 
with its varied forms establishes the diagnosis together with the slower and 
more protracted course resisting ordinary treatment. 

In the pseudoleukemia of infants (von Jaksch) we have a marked 
leukocytosis with splenic and hepatic enlargement coupled with a 
hypertrophy of the lymph nodes. 

Prognosis. — The etiological factor and the intensity of the leukocy- 
tosis present must be taken into consideration in framing the prog- 
nosis. A low red blood-cell count, reduction of the hemoglobin to below 
30 per cent., coupled with a high color-index, are unfavorable features; 
otherwise the prognosis is good. 

Chlorosis. 

This is an anemia characterized pathologically by a lowering of the 
hemoglobin without a marked decrease in the number of red cells and 
clinically by a greenish-yellow color of the skin. 

Etiology. — Girls at the age of puberty, especially those who work in 
factories, or those who have deficiency of fresh air and sunlight, are liable 
to chlorosis. Boys are occasionally affected. The stress of school duties 
and early social life predispose in the wealthier classes. 

Pathology. — Hemoglobin as low as 20 to 30 per cent, is commonly 
observed. The red cells themselves are somewhat below normal and the 
color-index is lowered. The leukocytes remain normal, unless complications 
are. present. 



DISEASES OF THE BLOOD. 385 

Symptomatology. — A striking pale green color of the skin, with pale 
mucous membranes, in a well-nourished girl who complains of languor and 
who has a capricious appetite, are symptoms strongly pointing to chlorosis. 
The blood examination will confirm the diagnosis. The disease runs a 
chronic course, and any of the following symptoms may be noted before 
the disease is arrested: Shortness of breath, hemic murmurs at the base 
of the heart and in the large vessels in the neck. There is some edema of 
the finger-joints. Rapid heart action with palpitation, gastric hyperacidity, 
constipation, and headache are quite common. Percussion may show an 
enlargement of the heart to the right. The temperament changes, the 
patient becoming irritable, fussy, or even hysterical. 

Diagnosis. — A careful examination should be made to exclude tuber- 
culosis (see Tuberculin Tests), gastric ulcer, and the status lymphaticus. 
The movements should be examined for the ova of the intestinal parasites. 

Prognosis. — This is good if radical changes are made in the daily 
life of the patient and complications can be excluded. The disease does 
not react as readily to iron therapy as other anemias and runs a more 
prolonged course. 

Pernicious Anemia. 

This is rare in early life. The characteristic blood changes establish the 
diagnosis. The red blood-corpuscles are reduced in number; megaloblasts, 
poikilocytosis. polychromasia, normoblasts and megaloblasts with myelocytes are 
found. The hemoglobin contents is considerably reduced. The color-index is 
high. The leukocytes are low and the lymphocytes relatively increased. The 
spleen, liver, and glands are not hypertrophied. As the symptoms, course, and 
treatment do not differ from those in adults, they have been omitted, the blood 
picture being presented for purposes of differential diagnosis. Blood transfusion 
offers the only hope of recovery. 

Leukemia. 

This is an uncommon disease in infancy and childhood, characterized 
by a great increase in the white blood-cells and changes in the spleen, 
bone-marrow, and lymph nodes. 

Etiology. — In early life syphilis, rickets, malaria, and the chronic 
affections in general are regarded as the possible causative factors. 
"Whether there is a specific infection, as has been claimed, is still unsettled. 

Pathology of the Blood. — Two forms are distinguished ; the 
myelogenous or splenomyelogenous leukemia and the less common lymphatic 
form. These are differentiated by their blood picture. 

Splexomtelogexous Form. — The white blood-cells are enormonslv 
increased — 100,000 to 500.000. Among these the myelocytes are found 
in large numbers. The polynuclear neutrophils are relatively increased. 
25 



386 



DISEASES OF CHILDREN. 



There is an increase in the large mononuclears, the polynuclear and mono- 
nuclear eosinophiles. The mast cells may be found in considerable numbers. 
Lymphatic Form. — The lymphocytes are enormously . increased, 
forming nearly the whole percentage of white blood-cells. Myelocytes and 

mast cells are sometimes found. In both 
forms there is a diminution in the amount of 
hemoglobin and in the number of red blood- 
cells with the presence of a few normoblasts. 
Symptomatology. — The onset may be 
acute, but a slow insidious onset is the rule. 
The pallor of the skin and mucous membranes 
with digestive disturbance may be the first 
symptoms noticed, or a sudden hemorrhage 
from the nose or blood in the stools may first 
attract attention. Vomiting and diarrhea 
become more and more frequent. Falls eas- 
ily cause ecchymotic areas. The abdomen is 
tympanitic and protuberant, and in one of 
our cases this was the first symptom to at- 
tract the mother's attention. The spleen is 
found enlarged and may touch the crest of the 
ilium. It may be tender on palpation. 

The lymph nodes are quite generally in- 
volved, especially the cervical group. On 
rectal examination the mesenteric nodes are 
found palpable. Even the lymphoid struc- 
tures in the naso pharynx are hyper- 
trophied. The liver is found enlarged and 
assists in making more striking the general 
abdominal enlargement. As the disease ad- 
vances, dyspnea, rapid heart action, and 
evidence. The child becomes somnolent, 




Fig. 109. — Leukemia ; mark- 
ings show enlargement of 
liver and spleen. 



obstinate constipation are in 
refuses food, and dies of exhaustion. 

Prognosis. — It is a fatal disease in the pure types. 

Pseudoleukemia of Infants. 

(von Jaksch's Anemia.) 
There has been and still is much diversity of opinion with regard to 
the disease having a distinct entity. We have had cases that conformed 
quite closely to von Jaksch's description and which seemed to develop from 



DISEASES OF THE BLOOD. 387 

a long-continued severe anemia. The disease is characterized by a grave 
anemia with leukocytosis, enlargement of the spleen, liver, and lymph 
nodes. 

Etiology. — Infants who have had secondary anemias or who have 
rickets and syphilis are predisposed. 

Pathology. Blood. — The red blood-corpuscles are diminished to as 
low as two millions. Microcytes, megalocytes, and poikilocytes are found. 
Xucleated red cells, normoblasts, and megaloblasts may be found. 

The white blood-cells are proportionately increased up to 50,000 or 
more. The differential count shows an increase in the mononuclears and 
polynuclears. The eosinophiles may also be increased. Myelocytes are 
seen, but are few in number. 

Symptomatoloy. — The infant is extremely pale, sallow, or cachectic. 
Slow but progressive emaciation is the rule. The infant shows little or 
no interest in its surroundings. The appetite is small and intestinal indi- 
gestion is frequent. The cervical lymph nodes are palpable and the liver 
and especially the spleen are enlarged. The spleen is easily palpable, feels 
hard, and it is not painful. The infant mav die of exhaustion or a 
complicating bronchopneumonia. 

Differential Diagnosis. — From leukemia it is sometimes with diffi- 
culty differentiated, but the lower leukocyte count, the scarcity of myelocytes, 
the less pronounced hepatic and lymph node hypertrophy will aid in 
classifying the disease. 

Prognosis. — This must be regarded as a grave blood disorder. 

The principal anemias are tabulated in the following chart with the 
blood conditions briefly enumerated: 



388 



DISEASES OE CHILDREN. 



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390 DISEASES OF CHILDREN. 

Treatment of the Anemias. 

The general management of these cases is of greater importance than 
the administration of drugs. The causes which have produced the anemia 
may or may not be clear, but the majority of cases are in all events bene- 
fited by a regulation of their daily life. If the causative agent, as para- 
sites, is found, treatment should be directed toward its removal. Sunshine 
and fresh air coupled with an easily assimilated diet as rich in proteids and 
organic iron as possible, should be considered as necessities for all the 
anemias. 

Aerotheraphy may be limited by the circumstances as in the case of 
the poor city child, but five hours a day in the open air can always be 
obtained even in the winter months by using the child's room, the roof, or 
the parks. 

The children are more benefited when removed to the country. If 
the child has been attending school, this should be discontinued and the 
amount of exercise curtailed. Rest in bed is necessary for the severe cases, 
but this should not preclude sun baths and fresh-air treatment. If possible 
the child should be cared for and entertained by one person so as to avoid 
undue excitement or fatigue.. 

A bottle-fed infant should gain in weight and strength if the formula 
is suitable to its requirements. If assimilation is at fault a wet-nurse may 
be required, or such changes and additions should be made to the food as 
will at least temporarily promote the digestive capacity. (See article on 
Infant Feeding.) 

Older children should have an individual diet list prepared for them 
which will contain especially such articles as fresh raw milk, eggs, green 
vegetables, rare meats, and fresh fruits. (See Diet Lists, p. 162.) Spin- 
ach, yolk of egg, and the legumes contain organic iron in largest quantities, 
and it is desirable that the deficiency in iron should be made up from the 
natural foods rather than iron preparations. 

Drugs. — In chlorosis the iron preparations are of distinct value, 
especially when given with a nutritious diet and baths. Many of the 
anemias are benefited by the scale preparations, especially the citrate of 
iron and ammonia and the bitter wine of iron. Several trials may be 
required to find the preparation of iron best suited to the individual case. 
The various peptonates often do well, as they are easily tolerated by the 
stomach, but other cases will apparently do better on the old tincture of 
the chlorid of iron, well diluted and given through a tube. In older chil- 
dren, Blaud's pill will often do good service. Fowler's solution should be 
given in addition to the leukemias and in pernicious anemia, beginning with 



DISEASES OF THE BLOOD. 391 

one drop three times a day well diluted and gradually increasing to the 
physiological result, care being taken not to produce symptoms of arsenical 
neuritis. Cod-liver oil is a valuable addition if it is well borne and does not 
produce an aversion to the ordinary diet. 

"We have used the X-rays in selected cases of splenic leukemia, but the 
results which at first seemed promising do not warrant its general use. 

Several of our severe secondary anemias not due to any recognized 
underlying cause, which have resisted all other forms of treatment, have 
been cured by transfusion of whole blood by the syringe-canula method. 
Once assisted the organism apparently is enabled to make new blood, for 
we have noted no relapses in this type. 

Purpura. 

In this condition subcutaneous hemorrhages, petechial or ecchymotic 
in type, appear spontaneously and form one of the symptoms of a disease. 
Different names have been applied varying with the location and extent of 
the hemorrhages. 

It is known as purpura simplex when the hemorrhages occur into 
the skin only, and purpura hemorrhagica when bleeding takes place into 
the mucous membranes or internal organs. 

Etiology. — Any infectious process at any time during its course may 
be accompanied with purpura. It especially occurs in children with scarlet 
fever, variola, measles, cerebrospinal meningitis, and with septic processes 
in any organ. 

Pathology. — Hemorrhagic exudates may be found varying with the 
type of the disease either in the skin, mucous membranes, or internal organs, 
or in all of these situations. The spleen is enlarged in those types occurring 
with marked infection. The study of the blood has thus far thrown no 
light on the pathology of the disease. Further study of the adrenal bodies, 
which sometimes show large hemorrhages, may explain the etiology of the 
disease and prove whether it is an infectious process, a pathological change 
in the arteries themselves, or whether it is due to vasomotor changes that 
allow the hemorrhage to take place. 

Purpura Simplex. — The purpura may appear suddenly in a child that 
is apparently well, but as a rule it is preceded by prodromal symptoms 
resembling those of intestinal disturbance. There may be lassitude, loss of 
appetite, even nausea or vomiting. The stools may be slimy from improper 
digestion, and a low grade of fever is present in older children, but little 
or no variation is noted in infancy. The tibial surfaces are usually first 
involved, the hemorrhagic areas varying greatly in extent in different sub- 



392 



DISEASES OE CHILDREN. 



jects. Tlie color soon changes from a purplish-red to a dark, mottled, 
bluish-black. There is no pruritus nor pain on pressure over these areas. 
Indefinite muscle or joint pains are complained of, but localized with 
difficulty. 

In cachectic or marasmus infants it is not uncommon to see these 
hemorrhagic areas appear over the abdomen or extremities. In any long- 
standing or exhausting disease in the early months of life, purpura may 
appear and must be regarded as of serious import. 

In older children, however, purpura simplex tends to recovery, 
although relapses sometimes occur when the outlook seems most bright. 




Fig. 110. — Purpura hemorrhagica. 



Purpura Hemorrhagica. — In contrast to the simple form, this is a 
much more serious condition with a rather severe train of symptoms. After 
a few days of indisposition, with nausea and vomiting, fever appears, rang- 
ing from 100° to 104° F., with prostration out of proportion to the symp- 
toms. At the same time that the hemorrhages appear in the skin, •there 
may be bleeding from the nose or mouth. Hemorrhages in the alimentary 
tract may occur and are noted by finding blood in the vomitus or in the 
stools. The fact must not be forgotten, however, that the blood may be 
swallowed and later appear in the vomitus or stools. Blood in the urine 
usually occurs in the beginning, but ceases when the child is put at rest. 
Localized areas of edema may be present and, as a rule, correspond to, 



DISEASES OF THE BLOOD. 



393 



although greater than, the hemorrhagic areas. Pain referred to the gastric 
region, headache, and anorexia are quite common symptoms which persist 
in spite of treatment. Sleep is broken, and delirium, especially at night, 
may occur. Coma resembling that of the typhoidal state occurs in the 
severe cases and may persist until a fatal issue takes place. 

Henoch's Purpura. — This symptom-complex, occurring as a rule 
in childhood, was first described by Henoch. The symptoms referable to 
the skin consist of a purpura, of varying degree, often accompanied by an 
exudative erythema and urticaria or a localized edema. Besides the above 
manifestations, there are lesions in one or more joints which resemble 
rheumatic fever. Colicky pains, with vomiting and diarrhea, are nearly 




Fig. 111. — Purpura hemorrhagica, — fulminant type. 



always present, but as a rule are not of long duration. As in purpura 
hemorrhagica, there may be hematuria or hematemesis. Albumin is gener- 
ally found in the urine. Recurrences are frequent and succeeding attacks 
may show wide variations in the symptoms. 

Schonleins Purpura. (Purpura Blicumatica.) — This form is char- 
acterized by a polyarthritis with the symptoms of rheumatic fever and 
purpuric hemorrhages. Circumscribed edema may be present. A variable 
amount of temperature occurs with the arthritis. Albumin is generally 
found in the urine. 

Purpura Fulminans. — A very rare but fatal form of purpura is 
designated as a fulminant type. The onset is sudden, occurring with high 
fever, convulsions or chills, vomiting, and marked prostration. The pur- 
puric eruption rapidly spreads over the whole body. The urine is scant and 
contains albumin. It most frequently occurs in children under five years 
of age, and what was formerly known as malignant or black scarlet fever 



394 DISEASES OF CHILDBED. 

and measles probably belong to this type. Hemorrhages into the adrenals 
have been recorded. 

Diagnosis. — The diagnosis of purpura is usually easily made from the 
hemorrhagic nature of the lesions which do not disappear upon pressure. It 
is to be distinguished from infantile scurvy in which there are present 
swollen, spongy, bleeding gums, and articular pain combined with a long 
history of cooked food. 

Prognosis. — In certain forms, as the simple and rheumatic, the prog- 
nosis is favorable, although it may persist for several weeks. Hemorrhagic 
purpura and Henoch's purpura have sometimes been attended with fatal 
results. The fulminant type is always dangerous to life. 

Treatment. — This must necessarily be directed to the underlying 
cause when this is known. Eest in bed with a carefully regulated diet, 
including raw fruit juices, is indicated. Five minims of a 1/1000 adre- 
nalin solution hypodermatically may be given if the hemorrhages are pro- 
fuse. In convalescence the tincture of the chlorid of iron is important. 
Transfusion of blood should be tried in severe cases. 



Hemophilia. 

Hemophilia is an hereditary blood disorder characterized by a tendency 
to inordinate bleeding from the vessels following a trauma, or spontaneously 
from the capillaries into the tissues. 

It is almost invariably transmitted through the mother, who herself 
may not have been a bleeder. The male offspring (the first born often 
escaping) is affected in the proportion of eleven to one of the female. The 
male may again transmit the disease through his daughter. 

~No characteristic blood changes or histological peculiarity of the vessels 
has been found. Coagulation is always retarded. The hemorrhages occur 
most frequently from the nose, mouth, genital organs, and lungs. Some 
trauma to these parts may be the first notice of the diathesis or the fact 
that slight, almost imperceptible blows produce subcuticular hemorrhages. 
Following a fall there may be internal hemorrhages or bleeding into a joint 
that may produce disability or subsequent anchylosis. Death has occurred 
from uncontrollable hemorrhage following circumcision or the extraction of 
a tooth. 

Treatment. — Marriages in the families of bleeders should be con- 
trolled or at least due warning of consequences given. 

Subcuticular hemorrhages are sometimes controlled by absolute rest, 
with ice applications and compression. Adrenalin 1/1000, or 1/500 adrin 



DISEASES OF THE BLOOD. 395 

solution, may be directly applied. Stypticin in doses of gr. ^ offers some 
hope of control. The gelatin solutions for subcutaneous use are to be 
deprecated, as they may be carriers of tetanus infection. Warm or rather 
tropical climates are the safest for the hemophiliac. Serial injections of 
whole blood — 30 c.c. once every week for six injections — has been of 
decided benefit in bleeders with recurrent frequent hemorrhages from the 
nose. 



CHAPTER XXIX. 
DISEASES OF THE DUCTLESS GLANDS. 

The Thymus. 

This small, ductless gland, of epithelial origin, consists of two lobes coming 
in contact in the median line. It is located during its greatest development partly 
in the lower part of the neck and partly on the anterior mediastinum, extending 
from the lower ecl^e of the thyroid above to the fourth costochondral articulation 
below. It is thus in relation with the trachea above and the great vessels and 
pericardium below. It is largest during the first two years of life and then 
atrophies, but occasionally it persists longer and may last until puberty. In the 
course of atrophy it disappears from the neck and remains behind the manubrium. 
Various authorities disagree as to its normal weight. From 14 to 20 grams are 
said to be the average weight during infancy, but Boviard finds it much smaller 
than usually stated. From 100 observations made on the normal size of the 
thymus in early life, he found it averaged not over 3 grams, in weight. The 
histological structure of the thymus is similar to that of lymph-glands, and it 
probably functionates as a blood-forming organ. 

Enlargement of the Thymus. 

Hypertrophy of the thymus may produce grave effects apparently from 
pressure. Two possible explanations may be offered — first, that the en- 
larged thymus pushes on the trachea and thus embarrasses breathing; 
second, that dyspnea may be caused by pressure on the phrenics or pneumo- 
gastrics. It is, however, difficult to prove the latter. Laryngismus stridu- 
lus and various forms of dyspnea, sometimes called " thymic asthma," have 
been referred to the enlarged thymus. The symptoms may eventuate in 
sudden death. 

The diagnosis of enlarged thymus by physical signs is rarely made 
positively during life. It may occasionally be palpated by deep pressure 
over the top of the sternum and there may be dullness on percussion behind 
the upper part of the manubrium extending down from both lateral borders 
of the sternum. The area of dullness on the sides of the sternum may be 
unsymmetrical. 

Status Lymphaticus. 
By this condition is understood a lowered vitality seen in connection 
with enlarged thymus and a general hyperplasia of the lymphoid tissue of 
the body. Sudden death from cardiac paralysis and asphyxia may ensue 
under anesthesia or from any intercurrent disease or irritation. Enlarge- 
ment may be noted of the superficial and deep lymph nodes of the neck, of 
the follicles at the root of the tongue, of the tonsils, of the adenoid tissue 
at the vault of the pharynx, and, on autopsy, of the lymphoid structures of 

396 



DISEASES OE THE DUCTLESS GLAXDS. 



397 




Fig. 112. — Marked enlargement of the thymus gland with its relations 
from an infant, 7 months old. 



398 DISEASES OF CHILDREN. 

the stomach and bowels. There may be some enlargement of the spleen, 
with hypertrophy of the Malpighian bodies. There may likewise be a 
proliferation of the lymphoid tissue of the bone-marrow. Drs. Musser and 
Ullom report the pathological findings to be practically constant in eighteen 
cases of status lymphaticus collated from the literature of the subject, 
consisting of an enlarged thymus, spleen, lymph glands, Peyer's patches, 
tonsils and pharyngeal tissue. While these conditions were not reported 




Fig. 113. — Radiograph showing enlarged thymus in a 14 mos. old child. 

in every case, the enlarged thymus, spleen, and some of the lymph-glands 
were constantly found. Cloudy swelling of the liver and kidney were also 
fairly constant lesions. German pathologists, especially Yirchow, have 
noted a lack of development of the heart and arteries. Thus the heart may 
be small and the aorta narrow and thin-walled. With this may be asso- 
ciated a lack of development of the sexual organs, sometimes reaching the 
condition of infantilism. Varying grades of rickets, with resulting mild 



DISEASES OF THE DUCTLESS GLANDS. 399 

or severe bony deformities, are seen in a large number of cases of status 
lvmphaticus. These children may show a fair amount of fatty tissue, but 
are usually anemic. Chlorosis or hemophilia may also exist. 

It is very probable that the disastrous results so often seen in status 
lvmphaticus are due to an autointoxication from a sort of lymphotoxemia 
having- its source in the lymphatic tissues of the body. The importance of 
recognizing the condition is very great not only in respect to anesthesia, 
but for guarding the prognosis in any intercurrent mild or severe disease, 
and as an explanation of certain cases of sudden death without any known 
cause. 

The diagnosis often cannot positively be made, but children or young 
adults with bony evidences of rickets, with much enlarged tonsils and 
adenoids, with generally hypertrophied lymph-glands, with the male genital 
organs or breasts undeveloped in the older subjects, together with an absence 
of pubic hair, should be considered as possible subjects of status lvmphaticus. 

In young subjects, attacks of laryngospasm, in conjunction with a 
number of these stigmata, will greatly strengthen the diagnosis. Congenital 
underdevelopment of the heart and arteries is usually accompanied by 
smallness of the surface arteries and a small pulse. 

The treatment consists in careful hygienic oversight, especially as 
regards food, fresh air. and warm clothing. Cod-liver oil and the syrup 
of the iodid of iron may be given. The hypertrophied tonsils and adenoids 
must be earlv removed, but without the administration of an anesthetic. 



Diseases of the Spleen. 

The spleen is not uncommonly found to be enlarged in infants and 
children. Its elastic, distensible structure makes it peculiarly susceptible 
to enlargement, especially from congestion, infectious, blood, or constitu- 
tional disorders. 

Its upper border lies on a line with the ninth rib, its lower border 
reaching to the eleventh rib. It is a safe rule to say the spleen is not 
enlarged if it cannot be palpated below the ribs. The position for palpa- 
tion should be that described on page 42 (see Fig. 15).. 



Inflammation of the Spleen. 

This occurs, as a rule, from a neighboring process or from trauma. Peri- 
splenitis may occur in syphilis, tuberculosis, peritonitis, and injuries. Older 
children may refer their pain accurately to the splenic region. In some cases a 
friction rub is distinctly felt. With the stethoscope a coarse friction sound, not 
unlike that in pleurisy, can be heard. 



400 DISEASES OF CHILDREN;. 

Chronic Passive Congestion of the Spleen. 

This is seen in connection with enlargement of the liver, tuberculosis, and 
in cardiac affections. 

Other Enlargements of the Spleen. — Sarcoma, although rare, has been 
observed as a primary condition. The tuberculous and syphilitic enlargements 
are nodular and irregular. Primary splenomegaly is accompanied by enlarge- 
ment of the liver and anemia. Hydatid cysts and abscesses have been reported, 
but are extremely rare. 

Disorders of the Adrenals. 

Reports of sudden deaths from hemorrhages into the adrenals have increased 
the importance of these structures in early life. In infants they are relatively 
larger, and destruction of their function, whatever it may be, is attended with 
serious results. 

Hemorrhage into the Adrenal. — The symptoms come on suddenly not 
unlike an acute infection. There may be vomiting and diarrhea with acute 
abdominal pain and, in some instances, a purpuric rash. The pulse is weak, the 
pallor is marked, and coma or convulsions may usher in the rapidly fatal endings. 

Addison's Disease. 

This is extremely rare in early life and is accompanied by the same symp- 
toms ; that is, slow progressive cachexia and bronzing of the skin as in adults. 
In nearly all cases tuberculosis of the adrenals is found on postmortem 
examination. 

The course is slow, sometimes extending over years, and the prognosis 
invariably bad. 

Treatment. — Restriction of muscular exercise and the general treatment 
suitable for the tuberculous is indicated ; the feeding of adrenal products, as the 
desiccated extract or glycerinated extract, may be employed or adrenalin in 
solution hypodermatically may be given. 

Hodgkin's Disease. 

(Adenie; Lymphaclenoma; Pseudoleukemia.) 

This disease very rarely occurs in children. The main features are painless, 
progressive, glandular enlargement, usually beginning in the cervical region, and 
without the blood changes of leukemia : enlargement of the spleen and liver and 
a pronounced anemia ; as a terminal condition tuberculosis or sarcoma may be 
associated, but in all probability neither of these conditions bears any relation 
to Hodgkin's disease. 

Symptomatology. — The enlargements generally first appear in the neck. 
The glands slowly but steadily enlarge. They are not painful to the touch. The 
axillary and inguinal regions are later involved. When the general health begins 
to be affected it will be found that both the superficial and deep glands are 
affected. From their position the nodes may produce various pressure symptoms, 
such as dyspnea or dysphagia. In the later stages pronounced cachexia develops 
with an irregular or remittent type of fever. The glands never tend to suppura- 
tion, although they may fuse and form large tumors. 

Differential Diagnosis. — It is distinguished from chronic adenitis by the 
history, the localization, and absence of cachexia. Tuberculin or the various 
tuberculin tests would be required to distinguish it in the absence of suppuration. 
Excision of a lymph node for histological examination is the safest course for 
absolute diagnosis. 

Treatment. — Thus far this has been quite unsatisfactory. Unless the diag- 
nosis is made when only a few glands are involved surgical removal is not 
advisable. 

The Roentgen rays have given some good results, but this should only be used 
by those accustomed to the work. Arsenic may be given in large doses in the 
form of Fowler's solution. Out-door life at the seashore is to be preferred. 



DISEASES OF THE DUCTLESS GLANDS. 401 

Acute Adenitis. 

This is an acute inflammation of the lymph-glands producing hyper- 
trophy of their structure. 

Clinically the lymphatic glands are of great importance, their function 
being to guard the circulatory system, since they are obliged to take up, 
destroy, neutralize, or at least hold in abeyance the numberless bacteria 
which block their channels, and it is only when overwhelmed and overpow- 
ered by these germs that they themselves become affected. 

Eecent investigations along these lines have sufficiently proved that 
inflammation of the lymphatic glands is due to absorption, from a more or 
less distant focus, of bacteria or their toxins. 

Accepting the crude classification of inflamed glands into acute and 
chronic, we find that the glands most frequently affected are the cervical, 
mesenteric, axillary, inguinal, bronchial, and mediastinal. 

The majority of children with enlarged glands have cervical adenitis. 
This is accounted for by the delicate epithelium of the skin of the face and 
neck and the mucous membrane of the mouth and the pharynx. These 
being largely exposed to irritations, to bacteria, and to traumatism, we find 
the glands easily overpowered. It is always necessary to seek the cause or 
focus of the trouble and, if possible, to remove it. 

Eemembering that the superficial glands drain the side of the head and 
neck, face and external ear, and that the deeper glands drain the mouth, 
tonsils, palate, pharynx, and larynx, we have a clue to the initial trouble. 
It is not to be forgotten that the primary focus may have cleared up or may 
have been apparently cured and forgotten, but still the glands remain 
enlarged. A careful history of the eruptive and infectious diseases must be 
obtained ; any irritations of the scalp, diseases of the ear, eyes, nose, throat, 
gums, or teeth must be taken into consideration. The importance of work- 
ing backward from the effect to the cause in these cases must be kept in 
mind. Either the superficial or deep nodes may be affected. Under two 
years of age the external glands are affected in the majority of cases, and 
they also have a greater tendency to undergo suppuration. When the latter 
is about to take place the gland becomes painful and tender and the over- 
lying skin is reddened. Restlessness and some degree of temperature is 
observed. As a rule, this takes place during the second week or it may be 
held in check by cold applications and result later. A spontaneous discharge 
of pus does not occur until the entire gland has been disintegrated. Occa- 
sionally there seems to be no apparent cause except anemia and debility 
for the glandular hypertrophy, but here we have a valuable clue to the 
treatment. 
26 



402 DISEASES OF CHILDKEN. 

The glands may at first show no acute inflammatory changes; they 
grow steadily and surely, and do not easily break down. Because of the 
slow growth and painless tumor, and with no local cause observable, we are 
justified in presuming the glands to be tuberculous. The tuberculin test 
(page 56) should be made. Such a condition by no means signifies that 
the child has pulmonary tuberculosis, although having once given entrance 
to these germs, the possibility of an extension is present. The cervical 
glands may infect the thoracic chain and thus infect the lungs. 

Chronic Adenitis. 

This may occur as a result of frequent attacks of acute adenitis or from 
persistent local lesions in the neighboring structures. It is also observed 
in children who are the subjects of status lymphaticus. The glands must 
be differentiated from tuberculous lymph nodes or those seen in Hodgkin's 
disease. 

Thoracic adenitis is in greater part of the chronic type and very often 
the glands are tuberculous. Loomis examined and found the tubercle 
bacillus in apparently normal glands. We may safely say that in a large 
proportion of tuberculous cases in children it would appear that the primary 
infection was in these structures, and that, contrary to Parrot's law, clinical 
experience shows that the glands may be involved without local lesions in the 
lungs. 

In a large number of autopsies in children we have found the medi- 
astinal and bronchial lymph-glands enlarged, sometimes pressing on the 
great vessels or against the bronchial tubes. In one case perforation of the 
cheesy bronchial gland into the adjacent lung was the cause of death. We 
cannot describe any definite symptoms invariably produced by these patho- 
logical glands, but occasionally we do get a persistent irritative cough caused 
by pressure on a bronchus or on the recurrent laryngeal nerve, or localized 
feeble breathing with sibilant rales due to compression of a bronchus. Per- 
cussion is unreliable, for the dullness may be due to the thymus. Eecur- 
rent attacks of bronchitis may, however, often be traced to hypertrophied 
lymph nodes in the thorax. 

The enlarged mesenteric and retroperitoneal glands of the abdominal 
cavity may alone give sufficient evidence of the old-fashioned tabes mesen- 
terica. The point of entrance of the offending germs in these cases is 
through the mucous membrane of the intestinal canal. If we find a gen- 
eral enlargement of the glands all over the body — a condition which 
Legrouz called microadenopathy, we have a valuable hint in doubtful cases 
of general tuberculous infection. On the other hand, the absence of hyper- 



DISEASES OF THE DUCTLESS GLAXDS. 403 

trophied lymph-glands and the enlargement of the liver and spleen is an 
important negative sign in chronic diffuse tuberculosis, provided we can 
rule out syphilis by the history of skin rashes, fissures, and the therapeutic 
test ; for here also we may have enlargement of the superficial glands. The 
glands, therefore, may assist in establishing a correct diagnosis; they may 
point out by their anatomical distribution the source of their own infection, 
or they may themselves be productive of pathological conditions in adjacent 
viscera. 

Treatment. (Acute.) — As has been above pointed out, the removal 
of the local focus of irritation is most important. If seen early the appli- 
cation of the ice bag or cold compresses of 50 per cent, magnesium sulphate 
solution may cause a subsidence of the process. The application of a 5 to 
10 per cent, ointment of ichthyol is also effective. If suppuration has begun 
the local application of heat will hasten the process. Incision and drainage 
are then indicated. Dietetic and hygienic measures are important. 

(Chronic.) — Any underlying cause, as a chronic eczema, adenoids, 
and hyjDertrophied tonsils, or a sinus, must be removed before treatment can 
be effective. 

The syrup of the iodid of iron must be given for a long period. The 
X-ray treatment has given some good results. Tuberculous nodes should 
not be removed unless the extirpation can be clean and thorough. 

Exophthalmic Goiter. 
(Grave's Disease; Basedoic's Disease.) 

This condition, which is rare in early life, is due to an increase in the growth 
and activity of the thyroid gland. Our cases have occurred at or about the time 
of puberty, especially in girls of the neurotic type. Hypereinic goiters occurring 
at the time of puberty must be distinguished from true Basedow's disease. 
Tachycardia is present in both conditions, but the exophthalmos, tremors and 
purposeless movements are not present. This variety often disappears suddenly 
when menstruation is well established. 

Symptomatology. — With the gradual enlargement of the lobes of the thyroid 
there may be noted symptoms resembling chorea. Nausea and vomiting at the 
sight of food may be the first symptom to call attention to the true condition. 
The child is apt to be irritable, easily excited and depressed if left without 
companionship. 

Physical examination will show a well-marked tachycardia, usually with a 
soft systolic murmur at the base. The eye later has a peculiar fixed, staring 
look, and is covered by the upper lid with difficulty. 

Graefe's sign, or the difficulty of raising the upper eyelids when the child 
is asked to look upward, is usually observed. Profuse diarrhea which is con- 
trolled with difficulty is rather frequent in early life. The sleep is disturbed, 
and several times during the day the face may become flushed and perspiration 
appears on the body. 

Course and Prognosis. — Rarely the course is very rapid and ends fatally in 
a few weeks. In the majority of cases the prognosis is slow, with steady 
emaciation and periods of remission. The younger the patient the better the 
prognosis. 



404 



DISEASES OF CHILDREX 



Treatment. — Rest in bed, both physical and mental, with a light milk and 
vegetable diet is required until the symptoms subside. The extremely rapid 
pulse may require cardiac sedatives. Ice-cold applications or alcohol compresses 
may answer. If not sufficient in effect, the tincture of strophanthus or digitalis 
may be required. The serum of Rogers and Beebe, of the Cornell laboratory, 
has proven of value in selected cases. The amount injected varies with the 
degree of toxicity and the duration of the disease. Galvanization with a mild 
current of three milliamperes may be used with advantage in conjunction with 
any form of treatment. Thyroidectin, beginning with 5 drops, three times a day, 
a product derived from the blood of a thyroidectomized sheep, is sometimes of 
distinct value ; it may be tried and continued if the pulse and nervous symptoms 
subside. 

Achondroplasia. 

Achondroplasia (fetal chondro- 
dytrophy) is a. rare affection in 
which there is a marked dispropor- 
tion between the head and trunk and 
extremities. This is due to an ab- 
normal process of endochondral ossi- 
fication at the junction of the 
epiphysis and diaphysis. The prin- 
cipal change is a defective formation 
of rows of cartilage cells in the col- 
umnar zone. There often occurs an 
overgrowth of periosteum in this re- 
gion, this tissue wedging its way in 
between the epiphysis and diaphysis 
from the periphery toward the axis 
of the bone. These processes both 
prevent growth in length of the bone. 
Achrondroplasia is a congenital 
condition, and the features are evi- 
dent at birth ; sometimes the parents 
are undersized or dwarfed. 

The extremities are mostly af- 
fected, leaving the head and trunk 
nearly normal; the length of the 
arms and the legs is greatly dimin- 
ished, the hands often reaching only 

to the trochanters, while normally they should reach to the knees. There 
is a redundancy of tissues around the thighs, making thick folds in the skin. 
Muscular tone is low and the joints are lax, consequently all these children 
are late in walking. The head is relatively large, the bridge of the nose is 
usually depressed, the tip of the nose is bulbous, the eyes are far apart and 




Fig. 114.— Achondroplasic infant. 



DISEASES OF THE DUCTLESS GLAXDS. 405 

in the infant the tongue may be thick, this being due to a real hyperplasia. 
As a rule, the fontanels are late in closing ; teething also is delayed. 

The bones are short and thick with enlarged epiphyses; curvature in 
the shaft of the long bones, which often occurs, is not due to softening, but to 
periosteal intrusion, which offers resistance to growth in length of the dia- 
physes. Frequently a marked lumbar lordosis is present, the sacrum being 
tilted upward and backward. Beading of the ribs, as in rickets, may be 
present. 

The hands are small and square, the fingers being short and nearly 
equal in length and blunted at the ends. The " trident deformity " (diverg- 
ence of middle and index-fingers from ring and little fingers) is often noted. 
The mentality in these children is not affected to any marked degree, al- 
though they are inclined to be backward. 

Prognosis as to life is good, but such children are always undersized. 
Organic extracts from the thyroid and pituitary glands are used in the 
treatment, although the results have not been satisfactory and are not to be 
compared in any sense to those obtained with cretins. For the differential 
diagnosis see the article on Cretinism, p. 408. 

Infantilism. 

This is a condition characterized by a retardation of bodily development 
out of all proportion to the chronological age. 

These children are always small in stature, underweight, undeveloped sex- 
ually, and retain the falsetto voice of childhood. Their mentality, however, is 
usually fair and they are capable of making good progress when placed in school. 

Two types have been distinguished. In the Brissaud type the children 
are somewhat cretinoid in appearance, the face being flat and chubby, the body 
plump, the hair sparse and fine on the head, and there is an absence of pubic 
hair. In this type, ossification and epiphyseal growth may be delayed. The 
juvenile state of the body and mind is long retained. 

The second, or Lorain type, is distinguished by the rather slender body and 
finer features, although the genitals and voice remain long undeveloped. The 
mentality is apparently unimpaired in this latter type. Herter has recently 
pointed out that in cases of infantilism an intestinal digestive disorder may be 
the etiological factor. He believes the Bacillus infantilis to have a direct 
relation to the disease. 

The intestinal bacteria are replaced by gram-positive bacilli. The mal- 
development is attributed to the loss of fat in the stools and the intolerance to 
carbohydrates. 

The cretinoid type reacts favorably for a short time to the use of thyroid 
extract. The Lorain type is not affected by this drug, and we are inclined to 
favor Herter's suggestion to treat the disease as a nutritional disturbance. 
Gelatin is recommended as of value. The diagnosis, however, would need to be 
made very early in order to obtain good results. 

Cretinism. 
(Myxedema.) 

Mvxedema is a disorder of metabolism, resulting from an alteration 
or absence of the thvroid bodv or its functions. 



406 



DISEASES OF CHILDREN. 



Cretinism. — Two varieties are recognized : The endemic and sporadic 
(infantile myxedema). It is with sporadic cretinism that we are concerned 
in this country. The symptoms are the result of the complete absence of 
the thyroid gland. 




Fig. 115. — Hand of a cretin, showing the undeveloped carpal 
bones and blunt fingers. 



Etiology. — Hereditary factors, such an syphilis, rickets, and tuber- 
culosis in the parents, seem to favor the development of cretinism. The 
disease rarely occurs in the tropical climates, and we have not as yet seen 
a colored cretin. 

Symptomatology. — Sometimes at the sixth month, or soon there- 
after, the mental dullness of the child is noted. It shows very little, if 
any, interest in its parents or surroundings. Even its toys are unnoticed. 



DISEASES OE THE DUCTLESS GLANDS. 



407 



Upon inspection, the face is found to have a stupid, vacant expression, the 
eyes are dull and are wide apart; the hair is sparse and coarse, the nose 
flattened and the bridge sunken. The head appears large and is set upon 
a short thick neck. From the thick lips a tongue apparently too large for 
the mouth protrudes, and saliva drools from the mouth. The general 
stature is quite characteristic. The child is markedly stunted, the abdomen 
appears proturberant, due to the anteroposterior curvature of the spine. 
The child appears well nourished or even obese. An umbilical hernia is 
quite generally present. The arms and legs appear short and stumpy. 




Fig. 116. — Characteristic trident hand found 
in inanv defectives. 



The hands are spade-like and the fingers blunted; X-ray examination shows 
characteristic changes in the carpal bones. On palpation pads of subcu- 
taneous fat may be felt over the upper part of the chest. The skin is found 
to be harsh and dry. The subcutaneous fat does not pit on pressure. 

The fontanel may be imperfectly closed. If held erect, the peculiar 
stature and prominent abdomen are intensified. The head will often show 
a disproportion from the normal, as will the length of the child to its years 
of life (see Diagram, p. 28). A cretin of eight or ten years may simulate 
in height a child of two or three years. The temperature is usually slightly 
subnormal. In older children a history will be elicited of marked mental 



•108 DISEASES OF CHILDREN. 

deficiency. The child does not learn to speak, often showing irritable or 
vicious temper, with uncleanly habits as to stooling or urination. The teeth 
are very apt to become carious soon after eruption, and stomatitis is fre- 
quently observed. Untreated cases form a good proportion of the so-called 
dwarfs scattered throughout the country. 

The blood examination shows nothing characteristic; usually, how- 
ever, there is a diminution of the red blood-cells and hemoglobin. The 
above description applies to the typical cretin ; however, we quite frequently 
meet cases exhibiting a mental deficiency plus some of the physical char- 
acteristics outlined above, but in a milder form. In the early months of 
life the condition often goes unrecognized because the physician has not 
carefully enough observed and watched the infant. These may be classed 
as cretinoids. If the examiner will keep this type in mind, he will be 
more likely to diagnosticate cases in infancy. 

Differential Diagnosis.— Mongolian idiocy, achondroplasia, infantil* 
ism, rickets, and chronic nephritis must be differentiated from sporadic 
cretinism. 

The Mongolian idiot is small in stature and somewhat mentally defi- 
cient, but the distinct slanting type of eyes with the more shapely bodies 
and their willingness to go about, quite readily distinguish them from the 
cretins. 

Achondroplasia. — The large heads, the very short arms and legs, which 
are in marked disproportion to the normal body length, added to their 
fairly well developed intellect, quite readily stamp the diagnosis. 

Infantilism. — The symmetry of body and normal mental development 
are strong distinguishing characteristics. However, the infantile voice and 
lack of genital development, with the child-like skin, may occasionally lead 
to a mistaken diagnosis of cretinism. 

Rickets. — . This condition should not be confounded, as in rickets the 
mentality is normal and the bony changes are quite characteristic, even when 
the child is dwarfed by its deformities. 

The therapeutic test should be applied whenever there is any doubt. 

Prognosis. — The importance of early diagnosis has been dwelt upon, 
as the prognosis is so much better the earlier the treatment is instituted. 
Up to the age of puberty comparatively remarkable changes result from 
treatment. Young adults receive only very meager benefit from the treat- 



DISEASES OF THE DUCTLESS GLANDS. 



409 




" 0) 

7. 5 

- % 



- o 








5 - 

iH O 



6 i 



410 



DISEASES OF CHILDREN". 



ment. Untreated cases usually succumb to some intercurrent infection 
and their mentality remains quite stationary. 

Treatment. — Desiccated thyroid extract, if fed to cretins, soon pro- 
duces wonderful changes in their physical and mental state. Thyroid 
extract, in large doses, it should be remembered, has a depressing influence 
on the heart and circulation, and should be carefully given if there is any 




Fig. 120. — Radiograph of hand 
and arm from Fig. 120, show- 
ing undeveloped carpals. 



Fig. 121. — Cretin, age 7 years, un- 
treated. 



cardiac lesion. It should be given in increasing doses to infants, beginning 
with one grain three times a day, and increased slowly to five grains three 
times a day. Older children may finally take twenty to thirty grains in a 
day if necessary and if no depressing effect is produced. (A case under our 
observation had so far improved as to locate the box of tablets hidden in the 



DISEASES OF THE DUCTLESS GLANDS. 



411 



clock. He ate sixty grains in all. He became somewhat cyanotic, but 
quickly revived under the influence of stimulation.) The treatment must 
be continued in fairly large doses, until a decided change has been reached 





Fig. 122. — Cretin, before treat- 
ment. (Dr. Long's case.) 



Fig. 123.— Same case after 
year of treatment. 



and further improvement docs not take place. Then smaller doses, that is, 
about ten grains a week, may be necessary throughout life to prevent a 
relapse into the former condition. The recession of the tongue, loss of 
adipose, and lack of drooling are the first signs of successful thyroid therapy. 



SECTION X. 
GENERAL DISEASES OF NUTRITION. 



CHAPTER XXX. 
NUTRITIONAL DISORDERS. 

Rachitis. 

(Rickets.) 

Rachitis is a general disorder of nutrition, complex in character, which 
affects the growing organism, and is characterized chiefly by changes in the 
hones, ligaments and muscles in conjunction with nervous symptoms. 

Etiology. — Although a number of theories have been advanced to 
explain the causation of rickets, none have displaced the generally accepted 
idea that rickets is a result of faulty nutrition. It is distinctly a disease 
of infancy and childhood, and generally a preventable one. It seldom 
occurs before the sixth month of life (although congenital rickets is not 
unknown), and is rarely seen after the third year. 

In this country it is more commonly seen among the children of for- 
eigners, especially the Italians and negroes. While it is undoubtedly more 
common in Europe than with us, still the number of cases seems to be 
increasing in our large cities where the hygienic conditions are poor. It is 
most frequently seen among the children of parents who, themselves, have 
suffered from nutritional disorders or who have been the subjects of alco- 
holism or tuberculosis. The enfeebled offspring of such parents are par- 
ticularly liable to rickets when they live in badly ventilated, sunless quarters 
and are improperly fed. The food may cause perversion of nutrition be- 
cause it is deficient in certain elements, as the proprietary foods, or because 
in quantity and character it overtaxes the digestive functions. It is rarely 
seen in breast-fed children unless the milk is deficient because of prolonged 
lactation, pregnancy, or disease. The proprietary foods and condensed milk, 
if constantly used without the addition of fats, are particularly liable to 
cause rickets. Under these conditions it may also occur among the better 
classes. 

Pathology. — The greatest changes are found in the bones. Clinical 
analysis shows that the bony structures in rickets are made up of two- 
thirds organic matter instead of one-third, as found in normal bones of this 

412 



XUTRITIOXAL DISORDERS. 



413 



age. A cross section of a long bone at its junction with the epiphysis shows 
an enlargement and an increase in the cartilaginous structure, which is 
engorged and vascular. The periosteum is easily removed and the medul- 
lary portion is soft and traversed with trabecular The long bones may be 

soft and brittle in an early case, 
but in cases of long standing they 
become unusually firm and hard. 
In the bones of the skull similar 
periosteal changes occur which 
produce abnormal ossification and 
calcification. Many of the liga- 
ments are imperfectly developed 
or abnormally stretched. The 
spleen is enlarged in about 10 per 
cent, of all cases. The liver and 
the spleen may be forced down- 
ward by thoracic deformities. 

Symptomatology. — The first 
evidences of rickets may escape 
attention unless the examiner con- 
siders the possibility after obtain- 
ing the history. Among the early 
signs are fretfulness, disturbed 
sleep and excessive perspiration 
about the head, in an anemic 
child. It is not easily comforted, 
and cries when moved as a result 
of muscle tenderness. In cases 
of longer standing, physical ex- 
amination will show backwardness 
in development. The infant may 
be unable to hold up its head, to 
sit up, or stand as a normal child 
at the same age. The muscles 
are. in general, soft and flabby, the abdomen is distended and tympanitic, 
and evidences of imperfect digestion are found in the fetid stools and in the 
constipation alternating with an occasional diarrhea. In spite of this the 
appetite is generally good, more food being taken than is digested. 

In more advanced eases the spleen is palpable, and the anemia becomes 
more marked. The subjective symptoms above recorded become more in- 







f m H^^k 




' ■ 




<£ § 





Fig. 124. — Extreme rachitis, showing 
marked bony deformities. 



414 



DISEASES OF CHILDREN. 



tensified, and changes in the bony skeleton occur which can be felt on pal- 
pation. Among these the beading of the ribs at the costochondral junctions 
forming the so-called rachitic rosary is the most characteristic. In infants 
parchment-like areas occur in the occipital bones, known as craniotabes, a 
finding which helps to establish the diagnosis. 

At the junction of the epiphysis and diathesis nodular bony enlarge- 
ments are felt, particularly at the wrists, ankles, and knees. The forehead 





Fig. 125. — Rachitis, mild form, 
with bow-legs. 



Fig. 12G. — Rachitis, showing 
pigeon-chest deformity. 



is marbled with enlarged veins and in shape is squared in front and flat- 
tened on top. The fontanels are late in closing, even the line of the sutures 
being palpable. Bosses may be felt in the center of the parietal bones and 
near the base of the temporal bones. At this stage there is generally an 
evening rise of temperature and an accelerated pulse rate. The body weight 
may remain stationary or the increase may be very irregular. Dentition is 



NUTRITIONAL DISORDERS. 



415 



a very irregular process. The first teeth are frequently delayed, sometimes 
erupting only during the second year, and then with much discomfort. 
They easily decay, sometimes eroding almost to the gum. 

Nervous Phenomena often develop in the rachitic infant. Among these 
the most characteristic is laryngismus stridulus. This glottic spasm may 
occur several times a day and sometimes results in carpopedal spasms. In 
others nystagmus, tetany, or inspiratory crowing develops from the nervous 
instability. Convulsions are not uncommon and recur from apparently 
slight causes. 

Deformities occur later in the disease as a result of the softened con- 
dition of the bones and the relaxation of the ligaments. Besides the de- 
formity of the head, the thorax shows marked changes. The rachitic rosary 
becomes more marked, due to a sinking in of the ribs in the axillary line 
and a flaring out of the ribs below. 

The thorax may be more or less funnel- 
shaped and appear very narrow at the clavicles, 
due to the abnormal flaring below. The ster- 
num may be drawn inward or pressed forward, 
causing the pigeon-breast deformity. The an- 
teroposterior diameter of the chest may be in- 
creased while the transverse diameter is lessened. 
Xot infrequently a well-developed groove or 
sulcus is formed running from the ensiform on 
either side of the scapular line. This is known 
as Harrison's groove, and results from the pull 
of the diaphragm, introthoracic pressure and 
the abdominal distention. These thoracic de- 
formities necessarily affect the organs and 
structures within. The lungs are impeded in their action, favoring the 
production of bronchitis, pneumonia, and pulmonary collapse. The heart 
action and circulation may be impaired with a resulting cyanosis. Pneu- 
monic affections are peculiarly resistant to treatment, and their chronicity 
may be responsible for lymph-node enlargements at the root of the lung. 

The bones of the extremities now show other changes besides the 
epiphyseal enlargements at the wrists and lower end of the tibia, which 
occur very early in the disease. The humerus may be curved outward, 
while the legs are deformed from the weight put upon them in efforts to 
stand or walk. Bow-legs, knock-knees, and deformities of the foot are 
thus produced. The peculiar sitting posture of these children sometimes 
induces curvature of the femur. 




Fig. 127. — Knock-knees in 
a rachitic child. 



41(5 DISEASES OF CHILDREX. 

The spine, owing to the relaxed condition of the ligaments, bony 
changes, and deficient muscular power, loses its normal curves, eventually 
becoming bowed from the cervical region to the pelvis. Lateral curvatures 
or scoliosis result from postural positions assumed while being carried in its 
mother's arms. The pelvis may suffer with the remainder of the skeleton, 
becoming flattened or shortened in its anteroposterior diameters. 

The Wood shows no characteristic changes. Simple anemia is always 
present. The hemoglobin may be reduced to 40 or 50 per cent. A moderate 
leukocytosis is occasionally obtained. 

Diagnosis. — There is no difficulty in making the diagnosis in well- 
advanced cases. In the early stages sweating of the head, anemia, marked 
restlessness at night, irregular dentition, pseudoparalysis, and a distended 
abdomen in a child exhibiting abnormal nervous symptoms, are often suffi- 
cient to suggest the diagnosis. 

Infantile paralysis may be distinguished by the electrical reaction or 
by obtaining mobility in the prone position by irritating the plantar surface 
of the foot. 

In hydrocephalus (see Fig. 145) there is a true enlargement, in place 
of an apparent enlargement, of the circumference of the head, with a bulg- 
ing fontanel. Syphilitic affections are monoarticular, while many joints are 
simultaneously affected in rickets. 

In Pott's disease the spinal deformity is angular and rigid, causing 
pain when attempts at motion or pressure are made. 

Course and Prognosis. — The disease itself, while chronic, has a tend- 
ency to arrest or recovery when changes are made in the dietary and sur- 
roundings of the patient. But even if a cure results, many of the bony 
deformities remain. While it is seldom a fatal disease, it influences the 
mortality in early life because of the lowered resistance which it engenders. 
These children more readily succumb to respiratory, intestinal, and infec- 
tious diseases. Under suitable treatment the disease may be arrested after 
two or three months, and further bony changes prevented. Nervous symp- 
toms, such as laryngismus stridulus, are very promptly controlled when the 
proper treatment is instituted. 

Treatment. Prophylactic. — The education of mothers and of school 
girls by settlement workers in matters pertaining to the feeding and hygiene 
of infants will do much to reduce the number of cases. Frequent regula- 
tion and supervision of artificially-fed babies by their physicians would 
prevent overfeeding with too strong formulae which so often occurs among 
the more intelligent classes. Examination of the breast milk in children 
who are not sufficiently developing may show a marked deficiency in the 



NUTRITIONAL DISORDERS. 417 

proteins or fats. Milk of this character may cause the development of 
rickets. Mixed feeding and improvement in the secretion should be 
attempted by proper food. 

Dietetic Treatment. — Dietetic instruction for the mother, an out- 
door life, and cleanliness are the necessary requirements for a cure. The 
food in the case of an infant must contain a sufficient amount of proteins. 
If the feeding has been on condensed milk and high dilution or the pro- 
prietary foods, properly modified cow's milk will in a short time produce a 
marked improvement. The modifications recommended for difficult cases 
of infant feeding should be studied in this relation, as the change must be 
so made that it will be compatible with the defective assimilation which is 
usually present. 

Older children should have a diet list especially prepared for them, 
which may contain fresh raw milk, yolk of eggs, butter, leguminous gruels, 
and vegetables suitable to their age. 

Hygienic Treatment. — Provision should be made so that the child 
may live as much as possible in the open air. In bright sunny weather at 
least five hours a day should be spent out of doors. A roof or a room with 
a sunny exposure and with open windows may be utilized .for this purpose. 
Daily baths to which a pound of sea salt is added are given, unless contra- 
indicated by muscular tenderness. Mild forms of massage, breathing exer- 
cises, and gymnastic treatment given in the second year of life are produc- 
tive of good results. 

Medication. — With the exception of cod-liver oil or olive oil, which 
is of value in older children, drug treatment is of little avail. Iron and 
arsenic may be given for the anemia after progress has been made in proper 
food assimilation. If phosphorus is administered, the oil or the elixir may 
be used, although this drug and the lime salts have not proven of any benefit 
in our experience. 

Deformities of the long bones may be prevented by not allowing the 
child to assume wrong positions and not encouraging him to stand or walk 
until the softness of the bones is overcome. The rachitic spine is corrected 
by keeping the child in the horizontal position in bed or on a frame. 
Surgical measures to correct bow-legs and knock-knees are necessary in the 
advanced cases. 

Congenital Rachitis. 

(Antenatal Rachitis.) 

Rarely we see infants born with well-marked evidences of rickets. The 

rachitic fetns develops the affection in its intrauterine existence, probably during 

the placental period of nutrition in consequence of disease or starvation in the 

27 



418 DISEASES OE CHILDREN. 

pregnant mother. The infant is born with changes in the bony skeleton which, 
although not well-marked, resemble those in a lesser degree found later in 
rachitic infants. Craniotabes, enlarged epipyses, and beaded ribs may be seen 
and palpated. 

Scorbutus. 

(Infantile Scurvy; Barlow's Disease.) 

Scorbutus is a constitutional disease due to a prolonged faulty diet and 
characterized by pain and swelling in the extremities, and hemorrhages into 
the skin and mucous membranes. 

Etiology. — Proprietary infant foods, the continued use of sterilized 
and incorrectly pasteurized milk, food almost exclusively of one kind, as 
condensed milk or cereals alone, are the factors which produce the necessary 
predisposition to intestinal putrefaction and toxemia, and which may result 
in scurvy after some weeks or months. Although it occurs in children 
under two years of age, the latter half of the first year shows the greatest- 
number of cases. Malnutrition from food not adequate to maintain devel- 
opment is also a causative factor of importance. The chemical changes 
brought about in the food by boiling or evaporation in dry heat for the 
purposes of preservation are essentially the underlying cause of the disease. 
The cases occur more frequently among the well-to-do than among the dis- 
pensary cases, as the latter cannot afford proprietary foods, and much 
sooner give a mixed diet. 

Pathology. — Subperiosteal hemorrhages occur in the long bones, espe- 
cially in the tibia and femur. The epiphyses show similar changes, usually 
in proportion to the involvement of the periosteum of the shaft. In some 
cases the periosteum itself, close to the bone, is infiltrated and thickened. 
The ribs in marked cases show these changes, especially on their margins. 
The spleen may be found enlarged and hemorrhages occur in the pericar- 
dium, pleura, liver, and into the muscles. 

Symptomatology. Mild Cases. — Attention is usually first attracted 
to the infant because it cries when handled. The tenderness is especially 
marked about the lower extremities. The child is extremely fretful, and 
usually anemic. It is not uncommon to obtain a history of some fancied 
injury which may be misleading. The infant will hold the limbs motion- 
less, usually in a position of flexion, and cries or screams when any attempt 
to disturb them is made. In some cases only one extremity may at first be 
tender. No fever and no swelling may be present at this stage in the early 
or mild types. Such a train of symptoms, when present in conjunction with 
a history of prolonged feeding with artificial foods which lack the essential 
quality of freshness, should be suggestive and the therapeutic test applied. 



NUTRITIONAL DISORDERS. 419 

If swellings are noted over the epiphyses in one or both extremities, 
with swelling and engorgement of the gums, the diagnosis is quite certain. 

Aggravated Cases. — In these unrecognized or neglected cases, hema- 
turia may be the first symptom for which the child is brought to the physi- 
cian, or it may have been treated for rheumatism because of the swelling 
and pain at the ankles. Careful examination will show spongy gums, bluish 
in color, which may bleed on pressure. If teeth are present the gums 
override them, and ulcerations may be seen. Anemia is a constant symp- 
tom. The appetite is lost, the child cries constantly when handled, and 
blood may appear in the stools. In exceptional cases blood is effused into 
the joints and the epiphyses may separate. Ecchymotic areas appear under 
the skin, especially over the swellings on the lower extremities, but may 
also appear over the ribs. Concomitant rachitic changes may also be noted 
due to the nutritional faults. About the orbit, conjunctival hemorrhages 
may be seen or even protrusion of the eye-ball. The face is usually swollen, 
or even edematous. Albumin and casts are sometimes found in the urine. 

A collective investigation by the American Pediatric Society gave the 
following symptoms in their order of frequency: Pain and tenderness of 
the extremities, sponginess or puffmess of the gums, disability, anemia, cuta- 
neous hemorrhages, hemorrhage from the rectum and hematuria. 

Diagnosis. — Infantile scurvy is rarely mistaken by those who are 
accustomed to obtain a good history and who make a systematic examina- 
tion. Traumatism, acute infectious arthritis, and osteomyelitis are differ- 
entiated by the swelling, which is mainly over the shaft of the bone, the 
absence of temperature, swollen gums, ecchymoses in the skin, pseudo- 
paralysis, and blood in the urine and stools. A radiograph will in ques- 
tionable cases complete the diagnosis. 

Course and Prognosis. — The prognosis is very good when the disease 
is recognized in its early stages and prompt treatment instituted. The 
development of rickets or extreme malnutrition may delay the cure in 
aggravated cases. 

The great majority, even the neglected cases, recover under anti- 
scorbutic treatment. Beneficial results are noted after a few days, the mild 
types showing remarkable changes within a fortnight. 

Treatment. Prophylactic. — The disease can be prevented by the use 
of some orange juice and untreated cow's milk in the dietary. Over- 
anxious mothers should be warned against repasteurization of their infant's 
milk supply. Since so much of our milk is now pasteurized, some orange 
juice should be given in conjunction with the formula, at least at the sixth 



420 DISEASES OF CHILDREN. 

month. Milk treated by the holding method of pasteurization is not likely 
to cause scurvy. 

Dietetic Treatment. — The food should be abruptly changed ; fresh 
raw milk, properly modified, is allowed. Orange juice, one ounce daily in 
divided doses, and expressed beef juice about one ounce during the day, in 
addition, are readily taken. /Older children should be given mashed pota- 
toes and minced vegetables, such as carrots or spinach. The limbs are 
encased in cotton wool and supported on a pillow until the tenderness dis- 
appears. Unnecessary handling should be avoided. Removal to the outer 
air should be made with the infant in its crib or on a pillow. The anemia 
needs no drug treatment, as it disappears under the dietetic management 
outlined above. 

Marasmus. 

(Infantile Atrophy; Athrepsia.) 

Marasmus is a very common functional disorder in infancy, character- 
ized by extreme emaciation resulting from inability to assimilate food. 

Etiology. — This is still obscure. It is usually seen in the first year 
of life. The greatest number of cases appear in institutions and in dis- 
pensary practice. Undoubtedly food poor in quality and given in great 
quantities, coupled with unsanitary surroundings, have a distinct etiologic 
bearing on the development of marasmus. If the digestive secretions have 
not been sufficiently developed by proper food, or if they have been over- 
produced for some time in efforts to digest abnormal food constituents, then 
the disorder may insidiously appear with symptoms of acid intoxication. 

It is rarely seen among breast-fed infants unless there is a marked 
perversion of the supply. 

Pathology.- — The gross lesions found in even a well-marked case of 
marasmus are surprisingly few. Microscopically, nothing characteristic 
can be described. The body is devoid of adipose tissue. The muscles are 
soft, pale, and thin. The overlying skin is dry and wrinkled. Hemor- 
rhagic areas are frequently seen beneath the skin and sometimes in the 
mucosa of the gut. The lungs are frequently involved, showing either 
hypostatic pneumonia, bronchopneumonia, or atelectatic areas. We have 
found these often in combination. The liver is somewhat enlarged and 
fatty. The spleen may be soft, but is not enlarged. The kidneys show 
degenerative changes or at least a cloudy swelling. The heart is small, 
with pale muscle fibers. The mucous membrane of the intestinal tract is 
extremely thin and pale. The stomach is usually dilated, and its lining is 
covered with ropy mucus. The agminate and solitary follicles stand out 



NUTRITIONAL DISORDERS. 421 

heard, most noticeable at the apex and transmitted toward the axillary 
more prominently and give the " shaven beard " appearance. The villi are 
not easily found, or in some cases are entirely absent. The lymph nodes are 
enlarged. In some cases connective-tissue changes take place in the intes- 
tinal mucosa in isolated patches. 

Symptomatology. — The train of symptoms begins insidiously. The 
mother usually brings the infant because she has noted emaciation in spite 

of the fact that the food has been 
the same or even increased in 
amount. The loss of weight, if 
recorded, is found to be steady 
but constant. The muscles be- 
come soft and flabby. The skin 
is loose and wrinkled. The facial 
appearance changes, due to the 
loss of fat, with a wrinkled fore- 
head and sunken cheeks. The fat 
pads over the buccinators in young 
infants remain, however, almost 
to the end. The abdomen and 
thighs show the emaciation quite 
early. The skin feels harsh and 
dry, and has lost its elasticity. 
The muscle tone, especially over 
the abdomen, is lacking. The 
emaciation progressing further, 
gives an u old man " expression 
to the face. This outward wast- 
ing that takes place corresponds 
with changes in the heart muscle. 
The pulse becomes weak, and an- 
emia of a simple kind is present. 

A striking feature is the in- 
satiable appetite. The infants will 
take an enormous quantity of food 
and still cry as if unsatisfied. 
The stomach dilates and vomiting may occur. The abdomen is distended 
with gas, and the liver may be palpated well down in the abdomen. The 
stools vary considerably. As a rule, they are mixed in color, with a greenish- 
yellow cast predominating. They contain much unchanged food, and the 
bulk is decidedly increased. The odor is musty and foul and almost charac- 




Fig. 128. — Marasmus. 



422 DISEASES OF CHILDREN. 

teristic. Diarrhea may follow after several days of constipated movements. 
Erythemata in the napkin region develop and persist. The temperature is 
rarely much above normal, although subnormal readings are not uncommon. 
The thirst in some cases is extreme ; the infants have a red, dry, and glazed 
tongue. A finger or the hand is sucked continually, which the mother 
attributes to hunger. The cry is a low moan or whine, and is not repressed 
when attempts at comforting the baby are made. In fact, it often cries 
more when disturbed. As the disease progresses the emaciation becomes 
extreme; the child resembling a living skeleton. The fontanel and eye- 
balls are sunken. Excoriations and bed-sores develop easily. Stomatitis is 
not infrequent. Otitis may develop. The breathing becomes shallow and 
feeble. Pneumonia, usually of the hypostatic variety, or convulsions, 
frequently bring on the fatal termination. 

If the disease is arrested, the improvement is noted first in the station- 
ary weight and improved condition of the stools. Later slight gains are 
made, however, with frequent discouraging remissions. Finally the gain is 
steady, but slow. 

Course and Prognosis. — The course is long and tedious, and even 
when improvement begins months are needed to regain a normal appearance 
and development. Unless the conditions are eminently favorable, the prog- 
nosis is extremely poor, the infant usually dying of some intercurrent 
disease. 

Treatment. — Since the disorder is the result of defective assimilation, 
and artificial feeding being at best the introduction of a foreign food, a 
good wet-nurse (see p. 107) should be secured whenever this is at all 
feasible. Maternal milk even for one or two months has been sufficient in 
our experience to turn the balance from inevitable disaster to beginning 
success. A change of surroundings, especially in the case of the poor in- 
fant, is the next consideration. A life in a country district, with plenty of 
fresh air and sunshine, is of the greatest importance. These infants should 
not be placed or taken for treatment in hospitals or asylums. Treatment in 
homes, preferably in the country, which are under the direct supervision of 
a physician, is much more satisfactory. If the child is being breast fed it 
may be found after examination that the character of the secretion may be 
improved, and meanwhile mixed feedings can be tried. If in spite of this 
no gain in weight is made, a radical change of the milk must be made. 

If artificial feeding must be resorted to, the problem is a very difficult 
one, and will demand a knowledge of the principles of infant feeding, so 
that the food may be adapted to the needs of the case at hand. A detailed 
history of the previous feeding is essential, and it is not unusual to find 



NUTRITIONAL DISORDERS. 423 

that these eases have gone through the gamut of almost every conceivable 
food in an effort to find something that will agree with the baby. 

Begin the dietetic management by clearing out the intestinal tract with 
calomel or castor oil. If there has been vomiting, lavage is indicated once a 
day for two or three days. A daily irrigation of the bowels with saline 
solution for the first week is rarely amiss (see pages 73 and 74). 

Feedings should be small in quantity, and contain at first protein and 
fat slightly above the caloric value necessary to maintain life. The gruel 
diluent should be converted by a diastatic ferment, and, if necessary, the 
milk may be peptonized. It is a good rule not to prescribe, no matter what 
the age, greater percentages than 2 per cent. fat. On the contrary, skimmed 
milk, fat free, up to two ounces to the pound of body weight, will' usually 
be tolerated. Xot infrequently the marasmic infant does not do well on 
any ordinary milk modifications, because the infant has been neglected too 
long or fed upon foods which do not react to the rennin in the stomach. 
Legume gruels, one to two ounces of the flour to the quart, with the addition 
of one teaspoonful of pineapple juice to each four ounces of feeding, is given 
until the stools change in character. TVhey alternating with the legume 
gruel (see section on Infant Feeding) is then cautiously tried, and as soon 
as it is tolerated, the yolk of one egg rubbed up with a quarter of a teaspoon- 
ful of sugar, is fed daily from a spoon. Milk may now be added gradually 
to the whey, and this mixture may entirely replace the gruel. If gain in 
weight is made and development progresses, milk and gruel mixtures con- 
taining 1.5 per cent, of protein, with the addition of sodium citrate, one 
grain to the ounce, may be given so that the rennin action may be controlled. 
As the digestive secretions improve the infant is able to adapt itself better 
to the form of food prescribed, and in this resembles again the normal baby. 

Progress will only be made by careful attention to every detail and a. 
study of the stools before making any advances in the strength of the food. 
The fats may be kept low with advantage; the protein being raised if the 
dejecta appear to warrant it until a satisfactory gain in weight is being 
made. 

Medication is only indicated to support the strength until the dietetic 
measures are sufficiently advanced to support life. For this purpose 
strychnin is valuable. Alcohol in any form, if given for any length of time, 
does more harm than good. Bismuth is occasionally necessary to allay 
intestinal irritation. 

Baths are decidedly helpful adjuncts in the management. Brine baths 
are especially valuable. They are given warm and followed by a brisk 
alcohol rub daily. Asthenic cases may at first need subcuticular injections 



424 DISEASES OF CHILDREN. 

of normal saline solution, or if the nutrition is sadly impaired, a 10 per 
cent, solution of dextrose can be injected in the attempt to save life. 

Diabetes Mellitus. 

This is a condition of persistent glycosuria rarely seen in childhood, and 
differing from the same affection in adult life by rapid wasting and a speedy fatal 
ending. 

Etiology. — While rarely, if ever, seen in young infants, the disease may 
occur in children, oftenest between the ages of five and ten years. Heredity is 
supposed to act as a predisposing cause, and a diet containing excessive amounts 
of starch and sugar may have a causative influence. The real cause and pathology 
of diabetes mellitus are as obscure and uncertain in the child as in the adult. 

Symptomatology. — Among the earliest symptoms noted is an excessive 
thirst. A child who has been previously well-nourished, besides drinking great 
quantities of water, is seen to be listless or irritable, easily tired and with a 
large and capricious appetite. Failure of nutrition and strength soon follow, 
and in a short time, possibly within a few weeks, the wasting becomes very 
appreciable. The urine is passed frequently and in large amounts. Several 
quarts may be voided in the twenty-four hours. The specific gravity is high, 
as in older subjects, and large quantities of sugar and occasionally diacetic acid 
and acetone may be found. Nocturnal incontinence is usually present. Irritation 
of the genital organs is sometimes caused by the passage of the sugar. The skin 
and mucous membranes are apt to be dry, and the former may show patches of 
eczema and occasionally boils. Itching of the skin may be marked and annoying. 
The wasting and loss of strength proceed with great rapidity and death is apt 
to ensue from exhaustion. In some cases the fatal ending is due to an inter- 
current pneumonia and in others to diabetic coma. The disease generally runs 
its course within a few months and usually under six months. The younger the 
child the more rapid is apt to be the course of the disease. 

Prognosis. — We have never seen a case recover in a young child. In any 
given case of glycosuria, the only hope is that the condition is temporary and due 
to an excessive ingestion of starches and sugars, the so-called alimentary glyco- 
suria. There will then be an absence of wasting and the other symptoms 
previously noted. 

Treatment. — The diet must consist, as far as possible, of milk, meats, fats, 
eggs, and green vegetahles. Von Noorden recommends oatmeal that has been long 
and thoroughly cooked, which then appears to be well borne by diabetics in 
spite of its starch, and he thinks it has a curative tendency. The weakness may 
be combated with alcohol and strychnin. Small doses of codein may also be tried. 



SECTION XL 
DISEASES OF THE UROPOIETIC SYSTEM. 



CHAPTER XXXI. 
DISORDERS OF THE URINE AND KIDNEYS. 

The Urine in Infancy. 

The somewhat vague and conflicting reports concerning the early 
secretion of urine are due to the difficulty of collecting it. The following 
methods have heretofore been relied on: Placing a small sponge or piece 
of absorbent cotton over the parts, which is intended to be saturated with 
the urine, and then squeezed out; in females, fitting a cup or wide- 
mouthed bottle or pus basin under the vulva to be held in place by the 
diaper; in males, placing a bottle or condom over the penis and holding it 
in position by straps of adhesive plaster. When these methods fail, as often 
happens, the only resort left has been the catheter, a soft-rubber catheter, 
about 6 size, being best to employ. In females, where the greatest difficulty 
is usually encountered, the employment of a catheter is not always easy, 
and several preliminary passages into the vagina often occur in the hands of 
the inexperienced. To obviate these difficulties and to make easy and safe 
the routine collection of the infant's urine for examination, a special urinal 
has been devised. It consists of an oval opening ending in a funnel that 
fits into the collecting vessel. For 
efficiency of application, two sizes have 
been found necessary. Xo. 1. (Small 
size). For infants under one year. 
Xo. 2. (Large size). For infants 
over one year. 

Place the large opening around the 
vulva in the female and over the parts in the male with the funnel pointed 
downward. Put tapes through the opening in the arms and fix by tying 
around the abdomen and both groins. To fix more firmly in place, put 
strips of plaster over the arms. Place the end of the funnel in the collecting 
bottle, which is kept in place by the diaper. If the infant is very restless, 
put a cork in the end of the funnel and dispense with the bottle. 

425 




426 



DISEASES OF CHILDREN. 



It was hoped that this apparatus would enable one to collect the full 
amount passed in twenty-four hours, but this has not proven feasible without 
constant watching, as the movements of the baby make a small leakage 
unavoidable. 

Character of the Urine. 

That the kidneys functionate before birth is shown by the bladder 
usually containing urine just after birth, and from traces of this excretion 
in the liquor amnii. The kidneys at this time are of relatively large size 
and more distinctly lobulated than in later life. There is a great discrep- 
ancy among the various writers as to the amount of urine passed during 
the early days of life. All agree that the infant passes a relatively greater 
amount of urine than the adult. Parrot and Robin state that the new-born 




Fig. 130. — Chapin's infant urinal applied. 



passes four or five times more urine, per kilogram of its weight, than the 
fully-grown subject. They also found that the urine at this time has always 
about the same composition, whether passed in the morning or evening. 
The quantity and product of each urination varies but little as the infant 
has no urine of sleep, digestion, etc., since he takes an identical food and at 
nearly the same intervals of time. These authors found that the morning 
voiding varied from 10 to 30 c.c. Small quantities may be voided every 
hour through the day and several times at night. There seems to be a 
concensus of opinion among various observers that during the first few days 



DISORDERS OF THE URINE AXD KIDXEYS. 427 

the young infant excretes about from one to three ounces of urine, and after 
this the quantity rapidly increases. At the end of the first week there may 
be from three to twelve ounces ; at six months, twelve to sixteen ounces ; at 
one and two years, from sixteen to twenty ounces; from two to five years, 
twenty to thirty ounces, and after that, approximating the adult. It must 
be confessed that these figures are general and tentative and seem to be a 
fair estimate after considering many conflicting figures of the various 
writers. The amount will vary in proportion to the quantity of fluid given 
as well as the action of the bowels and skin. 

The specific gravity is low, rarely rising above 1010 during the first six 
months. A few days after birth and until the end of the first month the 
specific gravity is very low, only averaging from 1003 to 1004, as urea and 
inorganic salts are not found in large quantity at this time. It then in- 
creases in density, but it is not apt to rise much above 1010 until after the 
tenth year, when it may reach as high as 1020. 

The first urine is clear colored, although it is sometimes reddish from 
an excess of uric acid and urates. In the latter case it may be scanty and 
passed by drops which discolor the diaper. The uric acid crystals may even 
form concretions in the pelvis of the kidney. Infants seem to form uric 
acid with great facility, but the proportion of uric acid to urea diminishes 
later, though comparatively large all through childhood. In proportion to 
the body weight there is relatively less urea excreted by the infant than by 
the child, although the latter excretes more than the adult. This may be 
accounted for by the active metabolism occurring in early life. 

The reaction is usually neutral or faintly acid. In the cases mentioned 
where large amounts of uric acid are formed and eliminated during the 
few days after birth, the reaction will be markedly acid. The reaction may 
be at times slightly alkaline without being considered abnormal. 

The question as to the presence of what may be considered pathological 
ingredients at this time and their significance is interesting, but one upon 
which various writers are not in accord ; some state that traces of albumin 
and hyalin easts are occasionally found during the first days of life and with 
little significance. Hyalin and even occasional granular casts may he 
found in the urine of the newly-born. Slight glycosuria has occasionally 
been reported during the early months, especially when sugar has been too 
freely given in the food. All through infancy traces of indican will be 
found in connection with gastrointestinal irritation. 

During the early years of life slight renal hyperemia appears to be 
very easily induced and to be coincident to almost any marked bodily 
disturbance. 



428 DISEASES OF CHILDREN. 

The rapid metabolism occurring at this time of life and the vulnerability of 
the kidneys will occur to everyone. A careful examination of the urine in 
various conditions is presented in the following series of cases from the babies' 
wards of the New York Post-Graduate Hospital. The first series includes 
eighty-six cases in which some disturbance of the gastrointestinal tract was 
present. No attempt was made to classify these cases, and they include simple 
indigestion, fermentative diarrheas, intestinal inflammation and marasmus. In 
a large number the condition was not severe, and such cases were purposely 
included in the list. Albumin was present in seventy-five cases in this series of 
eighty-six. Its presence was noted as follows : trace, twenty-nine ; faint trace, 
thirty-one; heavy trace, fifteen. Casts were present in thirty-seven cases, noted 
as hyalin, granular, epithelial, and mucous. There were sixteen deaths in the 
series, and of these fourteen had albumin present and ten both albumin and casts. 
In thirty-two cases an examination for indican was made and found present in 
twenty-two of the cases. The amount was estimated as follows: trace, four; 
faint trace, one ; heavy trace, seventeen. 

A series of fifty-seven cases of pulmonary diseases, such as severe bronchitis, 
pleurisy, and pneumonia, gave the following results : forty-nine had albumin 
in the urine, thus noted ; trace, thirteen ; faint trace, thirty ; heavy trace, 
six. Thirty-two cases had casts present, either hyalin, granular, epithelial, 
or mucus. Of the seventeen deaths in this series, fifteen had albumin present and 
ten both albumin and casts. An examination for indican in twenty-three speci- 
mens shows its presence in sixteen cases. Trace, two ; faint trace, two ; heavy 
trace, twelve. 

In forty-five cases of general illness, other than pulmonary and gastrointes- 
tinal, albumin was present in thirty-one cases. Trace, nine; faint trace, eleven; 
heavy trace, eleven. 

In eleven cases of cerebrospinal meningitis, nine showed heavy traces of 
albumin and casts. 

In a number of cases of cerebrospinal meningitis, with coma, a special 
effort was made to collect the twenty-four hours' amount. A baby of nineteen 
months passed 18 ounces, one of two years passed 16 ounces, one of three years 
passed 16 ounces, and one of four years passed 20 ounces. All of these specimens 
had traces of albumin and casts, and the urea varied from 1.7 to 2.7 per cent. 

It is evident that any disturbance of the bodily functions during in- 
fancy will often be accompanied by the presence of albumin and casts in 
the urine. Actual renal disease should not be considered to exist when only 
traces of albumin and a few casts are found, this is simply an irritation of 
the renal tubules accompanying a slight congestion and having no special 
significance. 

It would seem that we are justified in concluding that the urine of 
infants may contain traces of albumin and even casts without any very grave 
results. Even when actual congestion or parenchymatous inflammation 
exists for quite a long time, it may be remembered that in early age the 
kidney possesses a wide power of regeneration. 

The exceedingly fine tests now often employed in examining for 
albumin must be noted as one explanation of its frequent discovery. As 
small amounts of nucleoproteid are always present in urine, probably derived 
from the disintegration of the epithelial cells from some part of the urinary 
tract, such as the ureter or bladder, fine traces of albumin may come from 
such a source. 



DISORDERS OF THE URINE AXD KIDNEYS. 429 

Formation of the Kidney. 

First are noted two minute oval structures appearing about the seventh 
week of fetal life. As these masses develop into the kidneys, they assume 
a marked lobulated form, and this structural peculiarity persists until 
shortly after birth when this distinctively lobulated structure disappears. 
The kidneys are relatively larger in the new-born than in older subjects and 
are placed a little lower down in the abdomen. The suprarenal capsules 
nearly cover the kidneys at first and are relatively large all through child- 
hood. Malformations have been rarely noted, such as a fusion of both 
kidneys into an irregular, horseshoe mass. Congenital cystic kidneys have 
been occasionally reported due to stenosis of the pelvis, ureters, bladder or 
urethra, followed by a dilatation of the capsules of the Malpighian bodies 
and of the tubules. As a result, the kidneys may be greatly enlarged, con- 
sisting of a mass of cysts. A few cases of single kidney, supernumerary 
ureters, and other rare anomalies have been reported in the literature of 
the subject. 

Anuria. 

This term applies to a cessation of the urinary secretion. In the newly-born 
note should always be taken of the first passage of urine. Its non-appearance 
may be due to some congenital malformation in any part of the urinary tract. 
Delay in voiding at this time is most commonly caused by uric acid infarction in 
the kidneys. The highly acid urine may then pass in drops which dry upon the 
diaper and the nurse will report that no urine is being passed. Sometimes a 
reddish-brown, brick-dust discoloration is left upon the diaper, and the inexper- 
ienced may think that the infant has been passing bloody urine. There may be 
anuria for twenty-four hours from this cause without the infant showing any 
constitutional disturbance. Examination will usually show that the bladder is 
empty. There are occasionally cases in young infants where no urine is passed 
from twelve to twenty-four hours, as far as can be seen, and, as long as there 
is no apparent bodily disturbance, it need not cause undue alarm. In older 
children anuria may be caused by various drugs, such as phosphorus or arsenic ; 
by nervous disturbances, as from fright, hysteria, etc.: there may likewise be 
complete suppression in the course of acute nephritis. 

Treatment. — Before deciding that a case is one of true anuria, the bladder 
must be examined to be sure that we are not dealing with ordinary retention. 
To be absolutely sure of this, it may sometimes be necessary to pass a catheter. 
A soft-rubber catheter, carefully sterilized, about 6 size, is best employed in the 
young infant. When there is actually a stoppage of the urinary excretion, the 
kidneys may be stimulated into action by slowly injecting into the bowel large 
quantities of warm normal salt solution. Hot fomentations over the kidneys 
may likewise be tried. The best diuretic is pure water given frequently and 
freely. When the urine is scanty and very acid, the young infant may be given 
from one to three grains of citrate or acetate of potash every two or three hours 
in a tablespoonful of water. Obstinate cases may respond to agurin gr.v to a 
five-year-old child three times a day. 

Polyuria. 
A temporary increase in the amount of urine excreted may be caused by 
the administration of large qualities of fluid, such as milk or water, by irritation 
of the base of the brain, by hysteria, by the cirrhotic form of nephritis, or by 
diuretirs. As a rule, the condition is due rather to functional than organic 
disturbance. 



430 DISEASES OF CHILDREN. 

Diabetes Insipidus. 

When polyuria assumes a chronic form and there is a daily excretion of 
large quantities of pale-colored urine having a very low specific gravity, the 
condition is known as diabetes insipidus. The real pathology of this disease is 
not understood, but the prevailing opinion is that it owes its inception to some 
sort of neurosis. The causes are obscure, but cases have been reported where 
heredity seemed to be a factor and others seem to be coincident to injuries of the 
brain induced by falls or blows, and to the various forms of meningitis. The 
disease begins early in life, the majority of the cases reported being under ten 
years. An evacuation of very large quantities of watery-looking urine is char- 
acteristic of the disease, even as much as ten quarts may be passed daily. The 
specific gravity is very low, varying from 1001 to 1005, and the urine contains 
neither albumin nor grape sugar. Urination is frequent and may reach a condi- 
tion of incontinence. There is great thirst and the patients drink very large 
amounts of water to make up for the constant loss. The loss of fluid sometimes 
induces a condition of dryness of the skin and mucous membranes with dimin- 
ished glandular secretion. Palpitation of the heart, neuralgia, and headache may 
occasionally he present, and vaso-motor disturbances, such as flushing of the 
face. When the disease has lasted a long time the general nutrition is apt to 
suffer and the bodily resistance is lowered. In many cases, however, the appetite 
is good and the general health does not seem to be affected. While occasionally 
a case may recover spontaneously, the disease is usually chronic, lasting many 
years, and death finally ensues from some intercurrent disease. The diagnosis 
is made by noting the continual passing of very large quantities of pale urine 
with low specific gravity, but without grape sugar, albumin or casts of any kind. 
Excessive thirst is likewise always present. 

Treatment. — The best results will be attained by hygienic measures. The 
diet must be carefully regulated, only easily digestible articles being allowed. 
The ingestion of fluids may be moderately restricted. Warm clothing with a free, 
out-of-door life and a pleasurable amount of exercise are valuable hygienic 
agencies. Drugs have little effect upon the course of the disease. The following 
have been recommended : atropin or belladonna, antipyrin, the various bromids, 
ergot, and arsenic. 

Renal Calculi. 

Uric acid infarctions often are found in newly-born infants. They consist 
usually of uric acid or urates deposited in the straight tubes. The calices and 
pelvis of the kidneys may at the same time contain small masses of uric acid 
or the urates or ammonium and sodium. These concretions should disappear by 
the end of the first or second week. They are caused by the abundant excretion 
of uric acid during the first days with an insufficient supply of water to hold 
the salts in solution. As noted in another section, the urine may be passed in 
drops leaving a dark red stain upon the napkin, or there may even be temporary 
anuria in this condition. A true renal lesion is not apt to follow. A free ad- 
ministration of water will generally induce a solution and washing out of these 
deposits. Small calculi sometimes persist in the pelvis of the kidney or they 
may be formed later by the deposition of uric acid or the urates. When the 
calculi are not dissolved they may be washed down into the ureter and produce 
the symptoms of true renal colic. There is then acute pain in the region of the 
kidney radiating downward, with possibly even retraction of the testicle on the 
affected side. Small amounts of urine are frequently passed which may be 
tinged with blood. In older children there may be vomiting and marked evi- 
dences of prostration. When the calculi reach the bladder the pain quickly 
ceases. Prolonged acts of screaming on the part of infants, otherwise unaccounted 
for, are doubtless often due to the passage of small crystals of uric acid through 
the ureter. The only way to be positive, however, is to examine the urine when 
voided for the presence of these crystals. Occasionally, but rarely, a good-sized 
calculus may become impacted in the uretha. Examination may be made for 
this condition in cases of anuria, and evidences of local discomfort will be a 
guide for the search. The irritation of pelvic calculi may sometimes induce a 



DISORDERS OP THE URINE AXD KIDNEYS. 431 

mild form of pyelitis. Where a large calculus becomes firmly wedged in the 
ureter it may produce a complete stoppage which will eventuate in hydronephrosis. 
Treatment. — Young infants should be given water as a routine measure, 
from a teaspoouful at first to half an ounce later, several times daily, in order 
to keep the uric acid and urates in solution and flush out the kidneys and urinary 
tract. When the urine becomes scanty and high-colored the water may oe given 
even oftener. and one or two grains of citrate or acetate of potash added every 
three hours will form a good alkaline water. Older children must have their 
diet carefully regulated and fluids freely given. The indications for surgical 
interference are the same as in adults. 

Hematuria. 

The red blood-corpuscles may be present in the urine either from certain 
general disturbances of the body or from local causes in the genito-urinary tract. 
As an example of the first may be cited infectious diseases, such as variola, 
scarlet fever, or severe paludism : various blood diseases of obscure origin, such 
as hemophilia and purpura : scorbutus and large doses of irritating drugs, such 
as chlorate of potassium. Among local causes may be mentioned acute nephritis, 
new growths in the kidney or bladder, and calculi in the kidney, ureter, bladder, 
or urethra. Some help may be had in discovering the source of the bleeding by 
noting the condition of the urine as passed. If the blood is thoroughly mixed 
with the urine at this time, the source is apt to be in the kidney. Where the 
bladder is the sent of the hemmorhage, the blood is usually passed at the end 
of urination, while if the urethra is affected, the first urine passed contains the 
blood. Small amounts of blood in urine may give it a slightly reddish or smoky 
appearance, while large quantities may appear as clots. In any uncertain case 
the microscope must be depended on for the diagnosis. 

Treatment. — This must be directed to the cause, but small doses of the 
fluid extract of ergot may be frequently given if the bleeding continues. 

Hemoglobinuria. 
Hemoglobin may be present in the urine with very few or no blood-cells. It 
is occasionally seen in the same infectious diseases that may produce hematuria ; 
also from irritating drugs that are eliminated by the urinary organs as carbolic 
acid and chlorate of potassium. It is also rarely seen in an epidemic form, 
occurring in the newly-born, known as Winckel's disease. The diagnosis is 
made by the microscope which shows the blood pigment granules, but not the 
red cells themselves. 

Functional Albuminuria. 
{Cyclic or Physiologic Albuminuria.) 
An occasional albuminuria, without casts or other evidences of kidney disease, 
may be noted in children. It is more apt to occur shortly before or during 
adolescence. The cyclic form is apt to exhibit itself in the urine passed during 
the day, while the patient is on his feet, but disappears during the night and 
early morning. This is explained by posture, as there is no albumin pres- 
ent when the patient is lying down, but appears after the erect posture is 
maintained. Cold bathing, overexercise, too large ingestion of protein food, and 
various forms of indigestion and malassimilation have all been advanced to 
explain transient albuminuria. There are usually no symptoms, and the 
patient may even show all the signs of apparently perfect health. There is 
frequently the same uncertainty and obscurity in this condition in childhood as 
in later life. The cases should be kept under observation and if albumin persists 
very long, even in small amounts, there is probably some lesion in the kidneys. 
The condition of the heart and the tension of the pulse must be watched, as 
beginning hypertrophy and constant high tension point to kidney trouble. While 
being observed, the diet should be carefully regulated, overfatigue prevented, 
and attention given lo ^ronoral hygiene rather than to measures directed to the 
kidneys. 



432 DISEASES OE CHILDREN. 

Indicanuria. 

Indican in minute traces may be found in normal urine, but the condition 
may be considered abnormal when a marked reaction is given to the test. It is 
usually seen in the various forms of intestinal indigestion and fermentation. The 
putrefaction of proteins under the action of various bacteria results in a sub- 
stance known as indol from which the indican is derived. The condition is some- 
times also noted in tuberculosis, empyema and various diseases accompanied by 
suppuration. The treatment is dietetic and directed against the various forms of 
intestinal disturbance that are accompanied by undue food decomposition within 
the intestine. The color scheme and test for indican are given in the section 
on Special Tests (p. 52). 

Acetonuria and Diacetonuria. 

Minute traces of acetone and diacetic acid may be found in normal urine. 
They may be increased in fevers and in any condition accompanied by undue 
protein decomposition. They have been found in cases of diabetes followed by 
coma. 

Congestion of the Kidney. 

As the kidneys functionate very actively in early life, various grades of 
hyperemia may be easily induced. The various infectious conditions, marked 
digestive disturbances, high fevers from any cause, irritating drugs, and exposure 
to cold may be accompanied by traces of albumin and tube casts in the urine. 
This does not necessarily mean that there is the beginning of an acute nephritis, 
as the condition may pass away with the subsidence of the cause of the irritation. 
If the latter persists too long, however, actual nephritis may ensue. In a previous 
section, evidence was shown that almost any marked bodily disturbance, especially 
in infancy, will often be accompanied by the presence of albumin and casts in 
the urine. This may be simply an evidence of irritation of the tubules accom- 
panying a slight congestion. The urine may be scanty, but if there is nothing 
beyond congestion, even if extreme and followed by almost complete suppression, 
there will be a rapid improvement without leaving behind any appreciable lesion 
of the kidney. A congested kidney is apt to be somewhat enlarged as there is 
more blood in the vessels than normal, and if the condition has lasted for several 
days the cortex may be very red and have the gross appearance of cloudy 
swelling. 

The treatment includes keeping the bowels free and giving plenty of pure 
water. The latter is especially important in conditions accompanied by a great 
loss of fluid when the toxins circulating in the different organs in concentrated 
form irritate the delicate cell structures of the kidney as of the other vital 
organs, and hence need dilution and washing out from the system. The skin 
must be kept warm and moist and hot fomentations over the kidneys sometimes 
appear to be good. A milk diet is best. 

Chronic Congestion. 

(Passive Hyperemia of the Kidney.) 

Chronic lesions of the heart or lungs or any pressure effect that interferes 
with the general circulation, and thus with the kidney circulation, may result in 
chronic congestion. It occurs principally in older children. A long-continued 
impeded circulation through the kidney will be followed by enlargement of the 
organ caused by a distention of the vessels with blood. On section, a dark-red 
color is noted. The urine is passed in small amounts, with high specific gravity, 
and usually showing albumin and tube casts. 

The treatment must be directed to the skin and bowels, with the use of 
various diuretics, all of which are noted in our consideration of the treatment of 
nephritis. The principal treatment must naturally be aimed at the original con- 
dition that results in keeping up the congestion. 



DISORDERS OF THE URINE AXD KIDNEYS. 433 

Nephritis. 

In attempting to classify the various forms of nephritis from the stand- 
point of morbid anatomy, the student at the bedside will be much con- 
fused. It is often impossible to diagnosticate the anatomical varieties of 
nephritis by either a study of the clinical symptoms or of the urine. The 
physician frequently cannot tell whether he is dealing with acute conges- 
tion, acute degeneration, or acute glomerulonephritis of a mild type. From 
the standpoint of treatment, it is not very important to attempt to sharply 
differentiate these various disturbances. Nephritis will be here considered 
only as acute or chronic, although the synonyms will show the lesions that 
may preponderate in each Condition as far as the epithelial, interstitial or 
vascular tissues of the kidnev are concerned. 



Acute Nephritis. 

(Acute Parenchymatous Nephritis; Acute Exudative Nephritis; Acute 
Desquamative Nephritis; Acute Tubular Nephritis; Acute Glomerulo- 
nephritis; Acute Diffuse Nephritis; Acute Bright's Disease.) 
Definition. — An acute inflammation involving any or all (diffuse) 
of the histological structures of the kidney. 

Etiology. — Acute nephritis commonly occurs as a secondary condition 
in the course of the specific infectious diseases. Scarlet fever and diph- 
theria most frequently induce nephritis, but variola, varicella, measles, 
meningitis, typhoid fever, and influenza may also be noted as not infre- 
quent causes. Any severe disease, such as pneumonia or acute enteritis, 
may irritate the kidney to the point of inflammation in striving to eliminate 
noxious products. Thus the colon bacillus may be the irritating agent. 
Cases that are considered primary are doubtless usually due to some infec- 
tion that is obscure as to its point of entrance. The kidney lesions may 
be started by the toxins generated by infectious bacteria or may be caused 
by the direct action of the organisms themselves, in which case the disease 
assumes a severe type. Exposure to cold and wet may cause nephritis, 
possibly by checking the action of the skin and thereby throwing extra 
work upon the khlncys. or possibly by lowering the vitality so that various 
bacteria will grow sufficiently to infect the body, as in tonsillitis. The 
continued ingestion of drugs irritating to the kidney, especially chlorate of 
potash or the carbolic acid series, may induce nephritis. 

Pathology. — The kidneys are usually congested, soft and somewhat 
enlarged, the cortex being swollen and presenting the appearance of cloudy 
swelling. The pyramids generally appear congested. Tn other cases the 
28 



434 



DISEASES OF CHILDREN. 



kidney shows little apparent change to the naked eye. Under the micro- 
scope, changes may be noted in the epithelial, interstitial or vascular tissues. 
The various names have been given to the nephritis according to the tissue 
that is preponderatingly affected by the inflammation. When the glomeru- 
lar lesions are most marked, it may be called glomerulonephritis; if the 
glandular, epithelial cells in the tubules are mostly affected, we have 
parenchymatous nephritis ; if the stroma is principally affected, it is named 
interstitial nephritis. When all the anatomical structures of the kidney 

are markedly involved, it is called 
diffuse nephritis. The renal cells 
of the tubules, as seen under the 
microscope, show cloudy swelling, 
degeneration and sometimes des- 
quamation. The tubules may be 
filled with casts. In the glome- 
rular type, the cells covering the 
capillary tufts undergo swelling 
and proliferation. The cells mak- 
ing up the capsules of the Mal- 
pighian bodies may likewise un- 
dergo proliferation. There may be 
an infiltration of the stroma, with 
leukocytes and plasma cells and a 
production of new connective- 
tissue cells. The blood-vessels of 
the affected part are engorged, 
and there may be a proliferation 
of the cells of the capillaries. 

Symptomatology. — In early 
life, nephritis most frequently oc- 
curs as a secondary condition in 
the infectious diseases, especially 
in scarlet fever. It may come 
during the height of the primary disease or when the latter is subsiding. 
In scarlet fever it is more apt to ensue during the period of desquama- 
tion in the third and fourth week. The urine becomes scanty with a 
reddish-brown, smoky discoloration from the presence of red blood-cells 
or hemoglobin. Albuminuria is present, usually in marked degree; it 
may be so extreme as to change the urine into a solid on boiling. The 
urea is only partly excreted by the crippled kidneys, and hence accu- 




Fig. 131.— Puffiness of the face and 
edema of the extremities in a 
case of acute nephritis. 



DISORDEES OF THE URIXE AXD KIDNEYS. 435 

mulates in the blood. The amount of urea daily found in the urine 
is thus below normal. The specific gravity may be diminished, but when 
the urine is loaded with albumin it usually is as high or higher than in 
normal urine. Epithelial, granular and hyalin casts are usually found in 
abundance. Renal epithelial cells, red blood-corpuscles and leukocytes are 
also present. The temperature in nephritis is not apt to be very high, 
perhaps averaging from 101° to 102° F. ; if it goes much higher — -such as 
104° to 105° F. — it shows a severe type of the disease. The nervous 
symptoms vary with the severity of the attack. In mild cases there may 
be only apathy or restlessness and slight headache; in severer cases there 
is worse headache, dimness of sight, stupor, coma, or convulsions. A high 
tension pulse usually precedes the symptoms of uremia. The graver ner- 
vous symptoms usually come in connection with scanty or suppressed urine 
and they disappear as the secretion becomes more abundant, with a lessening 
of the amount of blood, albumin and casts, and a freer elimination of urea. 
The cerebral symptoms may be caused by a general edema of the brain or 
by a compression of that organ by an effusion of serum within the ventricles. 
The principal gastroenteric symptom is vomiting, without much or any 
nausea, and occasionally diarrhea is seen in the uremic state. More or 
less dropsy, due to a transudation of serum caused by the altered condition 
of the blood, is one of the commonest symptoms of the disease. It usually 
begins as a slight anasarca of the feet and ankles from whence it may extend 
up the legs to the scrotum and finally to the trunk. An effusion of serum 
in and around the internal organs with grave results may take place in the 
following usual order of frequency — edema of the lungs, effusion into the 
pleural and peritoneal cavities, into the pericardial sac. into the brain, and 
finally into the loose connective tissue of the larynx producing that alarm- 
ing and fatal condition, edema of the glottis. The anasarca is apt to pre- 
cede these internal effusions but this is not invariably the case. It is 
evident that dropsy as a symptom may induce little or no discomfort to the 
patient or seriously threaten his life according to the part of the body 
affected. The types of nephritis seen in different infectious diseases show 
some difference as far as the symptom dropsy is concerned. Thus in scarlet 
fever there is early seen a puffiness under the eyes and a swelling of the 
limbs, while in diphtheria it is rare to see any anasarca, even with a severe 
nephritis. 

The nephritis rarely seen in infants and young children, independently 
of the acute exanthemata, is sometimes called the primary form. This 
means only that the exact source of the agent that infects the kidneys is 
unknown. It may come from the tonsils or gastroenteric tract. Doubtless 
the colon bacillus is frequently responsible. The few cases reported in 



436 DISEASES OF CHILDREN. 

infancy have usually shown an abrupt onset, high fever, vomiting, and some- 
times diarrhea and a high mortality. In older children, the onset and 
course are less severe and the prognosis better. Dropsy is reported as 
uncommon in both varieties in so-called primary nephritis. 

The average duration of acute nephritis is from one to three weeks. 
The improvement in symptoms, and clearing up of the urine is gradual. 
Nephritis is usually accompanied and followed by marked pallor and anemia. 
While there is always diminution in the amount of urine, complete sup- 
pression is comparatively rare. The latter may exist for many consecutive 
hours and yet be followed by recovery. An examination of the bladder must 
always be made to be sure that retention is not interpreted to mean 
suppression. 

Complications. — The most frequent complications are referable to 
the heart and lungs — in the former, endocarditis and pericarditis ; in the 
latter, pneumonia and pleurisy. In rare instances meningitis may 
supervene. 

Diagnosis. — The recognition of the disease must rest principally on 
careful examinations of the urine. It may be suspected when moderate 
fever and pallor exist without apparent cause. 

Prognosis. — The younger the child, the worse the prognosis. After 
three or four years of age the prospect of recovery is good, especially if a 
fair amount of urine is passed and there are no marked evidences of uremia. 
If, however, there is a large number of casts present with a tendency to 
suppression, the outlook is graver. The mere amount of albumin passed 
is not of so much prognostic value. While a majority of the cases undergo 
complete recovery, there is always the possibility of chronic nephritis super- 
vening. This must be borne in mind in giving the ultimate prognosis and 
the urine should be examined at. intervals for a long time so that such a 
condition may be early recognized. Children may have a subacute or 
chronic nephritis with very few symptoms, and hence the condition may be 
overlooked during a long period of apparent health, or until an acute 
exacerbation brings on a serious or fatal result. 

Treatment. — Children suffering from infectious diseases, especially 
scarlet fever, should be handled carefully as far as the organs of elimina- 
tion are concerned — particularly the bowels and the skin. In this way 
the kidneys will be saved some of the irritation induced by the effort to 
eliminate the toxins produced by the original disease. Rest in bed, keeping 
the skin warm, and the use of mild saline laxatives, with milk and farina- 
ceous foods will usually be sufficient for this purpose. When nephritis 
supervenes, in spite of such care, more active measures must be employed. 



DISORDERS OF THE URINE AND KIDNEYS. 437 

These resolve themselves into a freer use of cathartics, diuretics and 
diaphoretics, with a fluid, unstimulating diet. The action of cathartics is 
usually more certain than other agencies. Calomel in doses of one or two 
grains is a good cathartic and diuretic as well. Citrate of magnesia, a few 
ounces at a dose, and compound jalap powder, ten grains to a child of five 
years, given every few hours, will prove helpful in relieving the kidneys 
through the bowels. Unstimulating diuretics, such as the citrate and acetate 
of potash, from two to five grains every two or three hours, are valuable 
remedies. A teaspoonful of cream of tartar to a glass of water, drunk 
freely from time to time, is a pleasant diuretic. Plain water, given freely, 
is one of the most constant and valuable diuretics we possess. It should 
always be frequently given in cases of illness of all kinds in children to 
insure a free action of the kidneys. The alkaline effervescing waters, such 
as vichy, will sometimes be taken in preference to plain water. Most of the 
diuretic remedies have diaphoretic effect when the skin is kept warm, while 
if the surface is cool the latter is lost and the result will be exclusively 
diuretic. In urgent cases, the muriate of pilocarpin will often have a 
most beneficial effect in producing free sweating and hence in relieving the 
engorged kidneys. To a child of three years, gr. 1/60 or even 1/50 of a 
grain may be given every five or six hours until results are obtained. -It 
may be given hypodermatically if a quick effect is desired, but, as it is 
depressing, stimulants must be given at the same time. The infusion of 
digitalis has a diuretic as well as stimulating effect, but it sometimes tends 
to upset the stomach. 

The hot pack affords one of the most convenient and efficient methods 
of acting on the skin. A blanket is soaked in hot water (110° to 115° F.) 
wrung out and packed around the patient's body. Hot water bottles are 
put in position and the whole is surrounded by a dry blanket. The skin is 
soon bathed in a profuse perspiration, and this may be repeated several 
times in the day if necessary. Hot saline injections (105° F.) given with 
a fountain syringe and soft catheter, or a double current tube, have a very 
beneficial effect in favoring kidney action. One or two quarts may be thus 
employed several times a day. During convalescence, some preparation of 
iron, preferably Basham's mixture, should be given for the anemia that 
always ensues. The diet all through the disease must consist principally 
of milk given freely. Some of the variations of milk often do better than 
whole milk. Thus skim milk, buttermilk, milk and vichy. kumyss, junket, 
and whey may be tried. The various farinaceous foods mixed with milk 
are also desirable as nourishment. Tt is important not to push the liquid 
diet undulv. 



438 DISEASES OF CHILDREN. 

Chronic Nephritis. 

(Chronic Diffuse Nephritis; Chronic Parenchymatous Nephritis; Large 
White Kidney; Amyloid or Waxy Kidney; Chronic Interstitial 
Nephritis.) 

Definition. — A chronic inflammation involving any or all of the his- 
tological structures of the kidney, but usually either prevailingly 
parenchymatous or interstitial, especially the former. 

Etiology. — It usually occurs as a sequel to one of the acute infections, 
but with especial frequency after scarlet fever. The interstitial variety 
is usually seen in older children in connection with hereditary syphilis. 
Valvular disease of the heart, alcoholism, and chronic tuberculosis may 
also be noted as causes. Prolonged suppuration, especially of bones or 
joints, is usually responsible for the waxy form. 

Pathology. — In the parenchymatous form, sometimes known as the 
large, white kidney, the organ is generally enlarged, with a yellowish- 
white appearance on section. The renal epithelial cells present a swollen, 
granular, or fatty appearance. The tubules may be contracted or dilated, 
and are usually filled with casts. There is compression of the tufts in the 
glomeruli from proliferation of the cells of the capsule and increase of 
connective tissue. The waxy kidney is usually much enlarged and presents 
the mahogany-brown discoloration with iodin. This form of degeneration 
is marked in the capillaries of the tufts and in the smaller arteries of the 
kidney. In the interstitial form, the kidney is small, with adherent capsule 
and nodular surface. The new connective tissue is distributed through 
the kidney in an irregular manner, producing a twisting or atrophy or dila- 
tation of the tubules, the latter sometimes forming cysts. The glomeruli 
may likewise be enlarged or atrophied into little fibrous specks. There is 
thinning of the cortex after the chronic interstitial change has become 
marked. 

Symptomatology. — The symptoms and course of chronic nephritis 
in the child do not differ in any essential way from the clinical manifesta- 
tions seen in the adult, especially as the disease is usually found in later 
childhood. In mild cases, there may be only general weariness, occasional 
vomiting and digestive disturbances, headache, and anemia. In severer 
cases, dropsy is a very constant symptom. The edema may be limited to 
the lower extremities and the vulva or scrotum, or there may likewise be 
effusion into the interior cavities, more often into the peritoneal cavity and 
occasionally into the pleura and pericardium. The dropsy is variable, 
sometimes being excessive and then suddenly clearing up for a time. 
Albumin is pretty constantly present in the urine, with hyalin, granular, 



DISORDERS OP THE UKIXE AXD KIDXEYS. 439 

and fatty casts. These abnormal ingredients vary in amount with the 
increase or decrease in the severity of the disease. The daily quantity of 
urine passed likewise varies from much below normal to about the proper 
amount. The progress of the disease is usually slow and very irregular, 
perhaps continuing for a number of years with occasional exacerbations 
when the symptoms become urgent, followed by periods of remission when 
the patient is comfortable. Eventually, death takes place from uremia or 
some intercurrent disease. In the chronic interstitial form, edema is rare, 
but there is the usual high tension pulse and enlargement of the left ventri- 
cle. As in adults, the nervous disturbances preponderate, such as headache, 
neuralgia, spasmodic dyspnea, poor vision, and dyspeptic troubles. The 
urine is passed, having a low specific gravity and frequently without 
albumin. Casts are not nearly so abundant as in the other and more 
common form of chronic nephritis. 

Complications. — Edema of the lungs and pneumonia may be con- 
sidered the most frequent complications. One may also look for pleurisy 
or endo- or pericarditis. 

Diagnosis. — The most objective symptoms leading to a recognition 
of this condition are a marked lessening in the quantity of urine passed 
and some form of dropsy. Poor nutrition, pallor, headache, high arterial 
tension and an enlarged heart should lead to careful examinations of the 
urine upon which the diagnosis must ultimately rest. 

Prognosis. — Complete recovery is rare. The symptoms, however, may 
rest in abeyance for long intervals of time. The disease may last for three 
or four years and the patient eventually succumb to some intercurrent 
trouble. The immediate prognosis becomes bad in the presence of very 
scanty urine and extensive dropsy. 

Treatment. — The management of the case must be largely hygienic 
and dietetic. The skin must be kept warm by flannels and, if possible,- the 
patient sent to a warm, dry climate. Sudden changes, with marked lower- 
ing of the temperature, are liable to be dangerous. If dropsy is present the 
cathartics, diuretics, and diaphoretics used in acute nephritis may be 
employed. The same is true of uremic symptoms. General tonics, and 
especially iron, may be constantly given. TVhile a fluid diet, principally 
milk, is the mainstay, it is sometimes necessary to allow a more generous 
diet, especially when anemia is extreme. The farinaceous foods can always 
be given, and it is sometinies an advantage to give meat in moderation. 
If weakness is great, the diet should be varied and more generous. 



440 DISEASES OF CHILDREN. 

Pyelitis. 

Definition. — An inflammation of the lining membrane of the pelvis 
of the kidney, often associated with nephritis or cystitis. 

Etiology. — Most cases of acute pyelitis in infancy are due to infection 
by the common colon bacillus. The disease occurs oftenest in females 
and the colon bacilli discharged with the stools ascend to the pelvis of the 
kidney by the vagina, urethra, bladder and ureters. It is possible that a 
certain number of the cases result from a hematogenous infection. Such 
infectious diseases as typhoid fever, scarlet fever and diphtheria may cause 
pyelitis. Congenital malformations of the kidney or ureter, tuberculosis 
of the kidney, and renal calculi may act as causes. There may be a direct 
extension of inflammation from neighboring structures, such as the kidney 
or bladder. Finally, general pyemia may be responsible for the disease. 

Pathology. — The pyelitis accompanying a general infection usually 
attacks both kidneys, while a purely local irritation involves only one side. 
The inflammation involves the mucous membrane of the pelvis and is of 
an acute inflammatory nature with congestion and infiltration of the cells 
and occasionally punctate hemorrhages. Pus is formed and passes out with 
the urine. It may quickly collect in such an amount as to distend the 
pelvis and calices of the kidney, thus leading to pyonephrosis. A pyelitis 
that persists is accompanied by more or less nephritis. The colon bacillus 
is found best in a catheterized specimen. 

Symptomatology. — These are somewhat irregular in character. 
Pain may be a prominent symptom, especially noted during urination. In 
other cases there is no evidence of local discomfort and not much besides 
pyuria to indicate the disease. A moderate, continuous fever may be 
present or, perhaps more often, the temperature assumes an intermittent 
character and may be accompanied by chills and sweating. In all cases 
of unexplained fever in early life with cachexia, this disease may be 
suspected and the urine carefully examined. The urine is turbid, with an 
acid reaction, and contains blood- and pus-cells and epithelial cells 
desquamated from the pelvis of the kidney. Albumin is present, sometimes 
from the pus and at other times as an evidence of accompanying nephritis, 
when epithelial, granular, or hyalin casts are also found. The urine is 
usually swarming with bacteria. If the pyelitis is of tuberculous origin, 
tubercle bacilli will be present in the urine. Occasionally large quantities 
of pns will be discharged into the urine from an abscess rupturing into the 
pelvis of the kidney. If the disease becomes chronic, puria may be the 
only constant symptom to be noted. There are also apt to be evidences of 



DISORDERS OF THE URINE AXD KIDNEYS. 441 

failure of health and emaciation in these cases. An examination of the 
blood in pyelitis usually reveals a leukocytosis. 

Diagnosis. — This rests finally on an examination of the urine, which 
when acid and containing pus and pelvic epithelium, will make the diag- 
nosis positive. Cystitis is rare in children, but examination for urethritis 
in the male and vulvovaginitis in the female must be made when pus is 
found in the urine. The acid reaction, however, indicates pyelitis. Pain 
in the region of the kidneys, irregular fever with chills and scanty urine 
point to pyelitis, but pyuria is the only constant and positive symptom. 

Prognosis. — The prognosis is good when the kidney proper has not 
become much much involved in the inflammation. Where there is extensive 
nephritis from calculi or pyonephrosis ensues, the prognosis is bad. 

Treatment. — A free administration of water to which citrate or acetate 
of potash has been added will serve to flush out the kidney and check the 
acidity of the urine. Two to five grains of these alkalies may be given 
every three hours. Hexamethelamin, in doses of two to five grains, three 
times a day, to a three-year-old child, is an efficient urinary antiseptic. The 
alkalies and the urinary antiseptic should not be given at the same time, 
as the latter acts only in an acid medium. If calculi are present and can 
be located, surgical treatment may give relief. The same may be true of 
pyonephrosis. See page 82 for vaccine treatment. 

Tumors of the Kidney. 

Very rarely there may be tuberculous growths in the kidney, usually in con- 
nection with a tuberculous infiltration of other portions of the genitourinary 
tract. The vast majority of cases in which a malignant growth attacks the 
kidney in the child are of a sarcomatous nature. The sarcomata are primary 
growths in these cases and may be followed by secondary growths in other 
organs, such as the lungs or liver. The growth may start in the pelvis of the 
kidney or in the adrenals or cortex. The increase in size is rapid and may pro- 
duce pressure effects on the various abdominal viscera, with ascites and rarely 
general peritonitis. Generally only one kidney is involved. 

Symptomatology. — The tumor is usually the first symptom to be noted. It 
steadily grows until a very great size is reached. The growth may usually be 
first noted in the side of the abdomen, but soon pushes forward to the middle, 
and in a few months may fill the whole cavity. Hematuria is sometimes present, 
and there is a rapid failure of strength and vitality. There will be pressure 
symptoms according to the size and direction of the growth. The patients rarely 
live beyond a year, and frequently not so long unless an operation is successful. 

Diagnosis. — The diagnosis is made by the rapid growth of a solid abdominal 
tumor in an infant or a young child. Practically all tumors of this nature at 
this time and in this position are sarcomata. 

Treatment. — The tumor must be removed as soon as recognized. While the 
mortality is high, a certain number of recoveries have been reported. See page 530. 



442 



DISEASES OF CHILDREN. 



Hydronephrosis. 

Hydronephrosis is a dilatation of the pelvis and calices of the kidney, often 
associated with necrosis of the kidney parenchyma, due to some obstruction to 
the outflow of the urine. It is seen more frequently in early than late childhood 
and about half the cases are found to be congenital. 

The obstruction may be situated anywhere in the genitourinary tract from 
the external meatus to the calyx of the kidney. The following causes may be 



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v ■■•■'■■ !'V* 


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V ; ^^ijjSff 1 


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Fig. 132. — Bilateral congenital hydronephrosis, caused by valve-like 
strictures in the ureters. From an infant 26 davs old. 



noted : Imperforate prepuce or meatus ; congenital stricture of the urethra ; con- 
genital hypertrophy of the bladder wall inducing stenosis of the ureters ; mis- 
placement of the ureters ; valve-like strictures in the course of the ureter or of 
the ostium pelvicum, showing a reduplication of the mucosa and of the muscularis 
from inflammatory change or abnormalities of development ; urinary calculi 
occurring after birth and, by their growth, occluding the urinary tract ; pressure 
by abnormal growths in neighboring organs or mechanical pressure from a float- 



DISORDERS OF THE URIXE AXD K1DXEYS. 



443 



ing kidney ; deformities of the skeleton or any foreign body in connection with 
the genitourinary tract. 

Hydronephrosis may be unilateral or bilateral, in the latter case the obstruc- 
tion usually exists in the bladder or urethra. The congenital form may be either 
unilateral or bilateral, but is usually unilateral. There will be extensive dilatation 
if the obstruction in the urinary tract occurs before the fourth month of in- 
trauterine life, as the secretion of urine begins about this time. When the 
hydronephrosis is unilateral, the other kidney will functionate vicariously. In 
some cases the obstruction may be only temporary or partial, when the affected 
kidney will retain part of its function. 

Cases of hydronephrosis of both kidneys are fatal during infancy, and the 
condition is usually overlooked, the babies dying of some intercurrent affection. 
In older children, with the unilateral form, the disease may be suspected or 
recognized when the dilatation is sufficient to produce a tumor in the lumbar 
region. Nephrectomy may then afford a radical cure if the other kidney is 
sound. Where hydronephrosis is due to an impacted calculus in a ureter, the 
condition is apt to eventuate in pyelonephritis. 

Enuresis. 

(Incontinence of Urine.) 
The symptom-complex of incon- 
tinence of urine can best be studied by 
considering, first, the phenomena which 
accompany the voiding of urine under 
the action of the bladder reflexes, and, 
second, the anatomical and physiologi- 
cal peculiarities accompanying this 
function in early life. 

The bladder, the spinal centers in- 
nervating it, and the brain holding an 
inhibition over the spinal centers, all 
have a part in this action. The follow- 
ing diagram, modified from Gowers, 
will give a suggestive idea of these 
parts : 

In the bladder we have the sphinc- 
ter (S), guarding the outlet by its tonic 
contraction, and the detrusor (D). or 
muscle of the bladder, usually dis- 
tended, but which, by its contraction, 
empties the organ. Both sphincter 
and detrusor are innervated by the segments in the spinal cord correspond- 
ing to the third, fourth, and fifth sacral nerves. The motor tonic centers 
for the sphincter (MS) keep this muscle in contraction, while the centers 
for the detrusor (MD) hold it in a state of dilatation corresponding to a 
positive and negative, or plus and minus action, of the motor nerves M\S 




Fie 1.°..°,. 



444 DISEASES OF CHILDREN. 

and MND. As the bladder becomes distended with urine, sensory impulses 
are transmitted by sensory nerves (SN") to the sensory centers of the cord- 
(SC) which are connected with the motor reflex centers (MS and MD) 
by association fibers. When the motor centers are sufficiently irritated they 
reverse their action, as a negative impulse ( — ) is sent down by the motor 
nerves MNS to the sphincter, which dilates, and a positive ( + ) action is 
transmitted by the motor nerves MND to the detrusor which promptly 
contracts. 

The action of a physiological, automatic reflex is thus shown. This 
action, however, is held in check by the inhibition of the brain (B) that 
holds a restraining influence on the spinal reflexes by nerve fibers connect- 
ing with them (MT and ST). It is usually necessary to relax the inhibi- 
tion of the brain before the automatic reflex can take place. Urination is, 
therefore, not so much a direct voluntary action as an indirect action of the 
brain in relaxing its hold on the spinal centers and thus allowing the 
automatic reflex full sway. 

In early life there are certain anatomical and physiological peculiari- 
ties that render the bladder and its reflexes very unstable. While the 
sphincter is weak, the detrusor is thick and powerful. In making autopsies 
on female infants the bladder, owing to the thickness of its wall, is some- 
times mistaken for the uterus. A powerful detrusor acting against a feeble 
sphincter thus renders the action of the bladder in retaining the urine 
unstable. In early life the spinal reflexes are also very active. The motor 
areas of the cord are relatively more developed than the sensory part, and 
hence motor actions preponderate. What would cause a sensory disturb- 
ance in an adult is reflected into a motor arc in the child and hence pro- 
duces a motor disturbance. This is exemplified in the beginning of severe 
illness, especially in acute infections, where the chill (sensory disturbance) of 
the adult is often replaced by a convulsion (motor disturbance) in the 
Child. This activity of the motor reflexes exhibits many forms in early life, 
especially in infancy, when the action of the spinal cord is most active, 
and the brain being as yet undeveloped fails to hold a proper inhibition on 
these lower centers. The watery brain of the infant, with relatively little 
gray matter, cannot hold the active reflexes of the spinal centers in proper 
equilibrium. 

There are two forms of incontinence — active and passive: (a) Active 
incontinence is produced when sufficient urine is present in the bladder 
to cause enough irritation of the sensory nerves to induce a contraction of 
the detrusor and dilation of the sphincter through the spinal centers. There 
is no paralysis, but either a lack of proper brain control or overaction in the 
cord. In this form the urine usually passes rapidly and in full stream. 



DISORDERS OF THE URINE AXD KIDNEYS. 445 

(b) Passive incontinence is caused by weakness or paralysis of the sphincter, 
and the urine usually dribbles away without ability of control. 

With the constant underlying predisposition to incontinence in early 
life, there are certain specific causes that may be mentioned in order to 
throw light on treatment: (1) Excessive acidity of the urine. Uric acid 
is readily formed in early life; in new-born infants crystals are often seen 
in the calices of the kidney. The urine may thus become so irritable as to 
be passed drop by drop, or with a reddish tinge that simulates the appear- 
ance of blood on the diaper. Other acids, such as the acid phosphate of 
sodium and lactic and hippuric acids, may be present in excess in the 
urine. Very small quantities of overacid urine often provoke incontinence 
by irritating the bladder, and thus stimulating the nerve reflexes to act. 
(2) Excessive irritability of the muscular coat of the bladder even when the 
urine is mildly acid or neutral. As the detrusor has an exaggerated con- 
tractile power in these cases, the urine is passed in a full and rapid stream. 
Even ordinary stimulation often causes strong contraction in the unstriped 
muscular fibers. This explains why atropin or belladonna acts almost as 
a specific when the muscle is thus at fault. (3) Weakness of the sphincter. 
This form occurs in feeble children who are in poor condition from severe 
illness or underfeeding, or where the innervation of the sphincter has been 
weakened by disease of the spine or spinal nerves. The urine is not passed 
rapidly nor in full stream, but is more apt to dribble away. (4) Reflex 
irritation from disturbances outside the bladder. The genitals, anal ring 
or rectum may present conditions producing sufficient irritation to cause 
frequent contractions of the bladder under reflex action. Phimosis, adhe- 
sions of prepuce to glans with retained smegma, stricture of the urethra, 
balanitis, vulvitis, ascarides, fissure of the anus and hard scybala in the 
rectum may be noted in this connection. (5) Neurotic causes. Children 
with unstable nervous equilibrium from chorea, epilepsy, and similar condi- 
tions are prone to incontinence of urine. Under psychical influence, 
especially in dreams, the child imagines a convenient place for urination 
and the reflexes act. (6) Vesical calculus may he a rare cause of incon- 
tinence, and, when acting, will he both diurnal and nocturnal, with urine 
turbid from mucopus and frequent painful micturition. (7) Malformation 
of flip bladder. Congenital deformities, such as extroversion of the bladder, 
rectovesical and vesicovaginal fistula 1 , and a few eases reported where 
ureters have emptied directly into the urethra, will be accompanied In- 
constant dribbling of the urine. 

Treatment. — Tt is evident from an ('numeration of the different causes 
that one kind of treatment will not be adapted to all ease-, and hence the 



446 DISEASES OF CHILDREN. 

physician must find, if possible, the principal reason for incontinence by 
an examination of the urine, together with a general and local physical 
examination of the patient. More than one cause will often be found 
present. Highly acid, scanty urine may be relieved by a free administration 
of water together with an alkali, such as the acetate or bicarbonate of potash, 
five grains of either thrice daily. Where overirritability of the detrusor 
is the principal cause, belladonna in full physiological dose, by its action 
on unstriped muscular fiber, will usually diminish functional activity and 
thus correct the condition. For a child of five years, grain 1/400 atropin 
sulphate or the tincture of belladonna, ^l v, may be given late in the day, 
and the dose increased until there is dryness of the throat and flushing of 
the skin. If the incontinence is not relieved when the drug is pushed to its 
full effect, it will not be necessary to continue it very long. Where there 
is evidence of weakness of the sphincter, nux vomica or strychnin and 
ergot will act in strengthening its tonicity and stimulating the nerve centers. 
From 5 to 10 minims of fluid extract of ergot and 5 minims of the tincture 
of nux vomica may be given thrice daily, well diluted in water, to a child 
of five years. Unlike belladonna, these remedies may have to be continued 
for several weeks before the full benefit is obtained. Occasionally good 
results will be obtained by a few hypodermatic injections of ten drops of 
the fluid extract of ergot directly into the ischiorectal fossa. Suppositories, 
containing half a grain of ergotin, may also do good in this class of cases. 
Incontinence of feces may have the same nervous causes and mechanism 
as incontinence of urine and may require the same treatment. 

The general hygienic treatment is always important. A simple, 
unstimulating diet, with a light, dry supper is desirable. Restriction in 
the amount of fluids, especially late in the day, may be tried. Postural 
treatment at night, with the buttocks elevated to save the neck of the 
bladder, has been advised, but is impracticable. General tonic treatment, 
such as the use of large doses of the syrup of the iodid of iron, will relieve 
certain cases. Cold bathing, and plenty of fresh air will act as adjuvants. 
The children should be taken up late at night and early in the morning, 
and placed upon a commode to prevent the bladder from getting too full. 
Punishing these children is unavailing and usually makes the matter worse 
by upsetting the nervous system. The trouble is apt to be more frequent 
and intractable in boys than in girls, and in rare cases may last for years. 
An intelligent study of the child's condition and a recognition of the prin- 
cipal cause in each case and an adaptation of the treatment to such specific 
cause will, however, usually bring relief. 



SECTION XII. 

DISEASES OF THE GENITAL ORGANS 

AND BLADDER. 



CHAPTEE XXXII. 
DISEASES OF THE GENITAL ORGANS. 
Phimosis and Paraphimosis. 

Phimosis exists when the prepuce is so narrowed or contracted that 
the foreskin cannot be freely drawn back over the glans. 

Hofmokl notes four causes of phimosis : 

(1) A prepuce congenitally too long and too narrow (hypertrophic 
form), (2) congenital narrowness restricted to the external opening of the 
prepuce, (3) long persistence of extensive epithelial agglutination between 
glans and prepuce, (-i) congenital and abnormal shortness of the frenulum 
and its location too far toward the front. 

Symptomatology. — Urination is frequent and painful. When about 
to urinate the child is very restless, and while voiding will often cry out 
with pain. Older children attempt to restrain the act as long as possible. 
In some cases the prepuce balloons out with urine as it passes or it may 
escape drop by drop. If the foreskin is very tight, drops of urine remain 
and decomposition of this retained urine often produces an eczema at the 
meatus or even on the thighs and over the entire genital region. Such 
inflammatory processes may cause balanitis. The habit of masturbating 
may be induced by the irritation. Following such a course, an infection 
may occur which may ascend through the urethra, sometimes, although 
rarely, causing urethritis and cystitis. Dilatation of the bladder and 
hydronephrosis may also result in neglected cases. Syncope and epilepti- 
form convulsions were formerly erroneously attributed to phimosis. 

If the foreskin be forcibly retracted over the glans, the pressure of 
the preputial ring in the coronary sulcus may cause strangulation. Such a 
condition is known as paraphimosis and soon causes violent pain. If this 
obstruction to the circulation is not relieved, edema and inflammation will 
occur, which later can produce ulceration and necrosis of the part?. 

Treatment. — The treatment of phhrio>i> with adhesion? con>i>ts in 
gently separating the agglutinated surfaces with a blunt probe and then 

447 



448 DISEASES OF CHILDREN. 

retracting carefully the foreskin over the glans. If this is not easily accom- 
plished the foreskin may be stretched by slowly separating the blades of a 
forceps until it is possible. Any smegma which is present is wiped away. 
If urine is retained in the foreskin, causing decomposition, circumcision is 
indicated rather than stretching. To relieve a paraphimosis, replace the 
glans within the prepuce by using the first and second fingers of both hands 
from below and with the thumbs above, forcing the glans through the con- 
striction. If this cannot be accomplished by manipulation, the strangulat- 
ing ring must be incised and cold compresses applied to reduce the swelling 
and inflammation. As a rule, circumcision is performed at a later date. 

Balanitis. 

This condition is usually due to an accumulation of smegma and retained 
urine, the decomposition of which causes an inflammation of the prepuce. Such 
accumulations occur most frequently where there is phimosis. Other causes of 
balanitis are masturbation, injury, and infection of the mucous membrane of 
these parts. There is redness and swelling of the free margin of the prepuce, the 
opening of which is often covered by small crusts. Several drops of seropus 
may appear if the opening of the prepuce is separated ; it is usually impossible 
to retract the prepuce entirely. 

Treatment. — Distend the prepuce by injecting an antiseptic solution, such as 
bichlorid of mercury, 1 to 5,000, or a weak permanganate of potash solution, 
three or four times a day. When this cannot be accomplished, apply the antiseptic 
dressing ice-cold. A solution of bichlorid of mercury 1 to 10,000 or liquor alumini 
acetatis N. F., one to four parts, is suitable. The wet dressings are applied until 
the swelling is reduced. Slitting up the prepuce to permit of thorough cleansing 
is sometimes necessary and then gives the quickest relief. All adhesions should 
be removed when this is done. Circumcision at this time should not be performed. 

Urethritis. 

Urethritis may be simple or specific. In the former, lack of cleanliness, 
injury or the passage of uric acid crystals are the usual causes. There is pain on 
urination and a slight discharge of pus. The inflammation is usually confined 
to the anterior portions of the urethra. There are no sequela? as in the specific 
form. 

Infection causing specific urethritis takes place by direct contact and can be 
diagnosticated only by a bacteriological examination. Gonocci are generally found 
in great numbers in the discharge. Except for the constitutional symptoms, which 
are mild or entirely absent, specific urethritis gives the same clinical picture as 
in adults ; that is, a thick purulent discharge and burning pain on urination. 
Complications are rare; those likely to arise are stricture, posterior urethritis, 
epididymitis, arthritis, and gonorrheal conjunctivitis. 

Treatment. — Hexamethelamin in 5-grain doses three times a day with rest 
in bed is usually sufficient, but in some obstinate cases it is necessary to irrigate 
the urethra with argyrol in a 5 per cent, solution or potassium permanganate in 
i per cent, solution twice daily. The pelvis should be covered to avoid carrying 
the infection to the eyes and the attendants warned of such danger. 

Vulvovaginitis. 

(Urogenital Blennorrhea.) 
This condition is a frequent cause of dysuria in girls, and may occur 
under the influence of general malnutrition, as in marked anemic conditions, 



DISEASES OF THE GENITAL ORGANS. 449 

uncleanliness, masturbation, when parasites are present, or following an 
infectious disease. The usual cause, however, is an infection by Xeisser's 
gonococcus. 

In this specific form infection takes place by either direct sexual con- 
tact or by handling, contact with the infected bed linen of parents, and 
less frequently from towels or discarded dressings. Epidemics of vaginitis 
frequently occur in hospitals and especially in institutions for children. 
Differentiation of the simple and gonorrheal types is based on the bacterio- 
logical examination of the pus. 

Vulvovaginitis begins with redness and swelling of the parts and a 
discharge of pus, which is usually yellowish or white in the simple form 
and greenish in the gonorrheal. The pus is abundant, and on drying 
forms crusts, causing the labia to adhere. Micturition is frequent and 
painful, due to contact of the urine with excoriations of the mucous mem- 
branes of the urethra and the labia. There is also pain on locomotion, due 
to the excoriated thighs. In severe cases pus may be seen oozing from the 
cervix. The vaginal mucous membrane bleeds easily, due to the excoria- 
tions present. Constitutional symptoms are infrequent, but buboes occa- 
sionally occur and may even suppurate. In the gonorrheal form the usual 
adult complications may occur, such as arthritis of the large joints, con- 
junctivitis, and cystitis. Salpingitis and general peritonitis have occurred 
in our service. On the other hand, the symptoms may be so mild as to 
cause no disturbance, and are only diagnosticated as specific in the labora- 
tory. This type is more apt to be seen in institutions than in private 
practice. 

Treatment. — Treatment of all vaginitis cases requires isolation of the 
case and scrupulous cleanliness as regards the patient, the linen, and the 
dressings as well as the attendant's hands. In severe cases the patient 
should be in bed. In the simple form, after removing the cause, irrigate 
the parts two or three times daily with warm normal salt or boric acid solu- 
tion?, bichlorid of mercury 1 in 10.000. or formalin solution 1 in 5.000. 
Cover the thighs and vulva with unguentum zinci oxidi or stearatis. A 
sterile pad is applied over the parts. 

In gonorrheal cases this treatment may be supplemented by the use of 
vagina] suppositories of argyrol 10 per cent, in oleum theobromatis : insert 
one after each irrigation. In all cases general tonics are indicated. 

In simple cases under treatment the course of the disease is about two 
or three weeks. The gonorrheal form lasts much longer, often for months, 
and relapses are frequent. Some seem to assume for a time a latent form. 
29 



450 DISEASES OF CHILDREN". 

which is apt to become active when the resistance is lowered from inter- 
current disease. 

Vaccine Treatment. — The vaccine treatment may be tried in intract- 
able cases or for a series of cases in an institution. A dose too large or too 
small gives little or no response, five million dead bacteria being the pre- 
ferred initial dose. Under this treatment clinical evidences of gonorrhea 
disappear in ten to twenty-one days, and no gonococci can be found in the 
smears for some time. 

In some cases a polyvalent vaccine seems more efficient than a univa- 
lent one. The best results are obtained when the vaccine used is obtained 
from the patient's own organisms, except where the case is of long duration 
or has been treated by antiseptics, as these lower the virulency of the organ- 
ism ; it is then better to make vaccine from a strain of known high virulence. 
Experiments have proved this step to be most efficient in spite of Torrey's 
conclusion that " the family gonococcus is heterogeneous." 

If an eye should become infected, the injections should be given at 
once, using temporarily a stock vaccine (see p. 78). 

As a rule, the discharge increases for the first two or three days after 
the injection, and then diminishes quite rapidly. However, the vaccine 
treatment is many times unsuccessful, and a case should not be considered 
cured until a long period of quiescence has elapsed without recovery of the 
organisms. 

Masturbation. 

In infants and very young children the presence of some organic source 
of irritation in or about the genitalia is assumed as the cause of masturba- 
tion. Of such irritations itching, vulvar eczemas, and pin worms which 
have escaped from the rectum and found their way into the vagina are the 
most frequent causes in girls. Attempts to relieve this irritation by scratch- 
ing or rubbing the thighs together results in the persistence of the habit 
because of the sensations it produces. In boys, an elongated prepuce, fric- 
tion from a phimosis, excoriations at the meatus from a highly acid urine, 
may be the original cause. In girls, adhesions about the clitoris from 
smegma and uncleanliness are common causes. 

In older children the beginning of such a habit is more probably due 
to acquaintance with others with whom the practice is in vogue; in some 
cases, accidental discovery that genital irritation produces voluptous sensa- 
tions occurs in certain sports, such as bicycle-riding or tree-climbing. 

It is an error to assume that this practice produces nervous, irritable 
children, with pallor, headache, and sickly appearance and dark rings under 
the eyes unless masturbation be indulged in to excess. In children of the 



DISEASES OF THE GEXITAL ORGANS. 451 

neurotic type such symptoms are, however, greatly aggravated by the violent 
sexual excitement so produced. 

Treatment. — It is essential to remove the cause. By the use of suit- 
able night gowns and bandages children can be prevented from masturba- 
tion at night. During the day constant supervision is desirable, but the 
early evening and early morning are critical times. Dietetic changes and 
psychic treatment after suitable explanation are potent factors in eradicat- 
ing the habit. Effort should be made to keep the child occupied all the time, 
and frequent diversion of the mind toward active and healthy normal chan- 
nels will prove most efficient measures. Cold affusions to the spine may 
be employed in intractable cases. 

Hydrocele. 

"When the peritoneal sac surrounding the testicle and epididymis is 
distended with fluid, the condition is known as hydrocele. It is not 
uncommon, and is usually congenital in origin. 

The following varieties may be differentiated: 

Hydrocele of the Tunica Vaginalis (with the funicular process oblit- 
erated). — This is one of the most common forms found in children. The tumor 
formed is oval and is firm and tense. It may occur on one or both sides. The 
tumor cannot be reduced. Fluctuation can usually be obtained, and the site 
of the testicle can be seen by illumination of the scrotum. The cord is felt above 
the rounded upper portion of the swelling, and the testis is generally situated 
posteriorly, projecting into the cavity, and is therefore not readily detected by 
manipulation. 

Congenital hydrocele exists when the funicular process is patent. The 
signs above stated exist except that upon manipulation the fluid can be returned 
to the abdominal cavity. 

Infantile hydrocele occurs when the funicular process is closed at its upper 
extremity only. The fluid extends along the cord, and the tumor is therefore 
elongated : tbe other signs are the same as given above. 

Encysted hydrocele of the cord is one in which there is an additional 
point of obliteration of the intraabdominal portions of the funicular process 
above the internal abdominal ring ; fluid distending this portion of the canal 
forms a tumor resembling a cyst in addition to the tumors in the scrotum. 

Treatment. — As a rule, no treatment is required. After several 
weeks the condition spontaneously disappears. If phimosis is present this 
should be corrected at once. In more resistant cases puncturing the sac 
and allowing the fluid to thoroughly drain off usually produces a cure. If 
relapses occur, instillating one or two drops of the tincture of iodin in ten 
drops of water will set up adhesions sufficient to obliterate the sac. In 
some of the congenital forms, a truss may be applied in order to obliterate 
the funicular process, and then if a cure is not affected aspiration is per- 
formed. If the hydrocele is associated with a hernia a suitable truss must 
be worn after the evacuation of the fluid. 



452 DISEASES OE CHILDREN. 

Undescended Testicle. 

( Cryptorchidism. ) 

When not in the scrotum, the testis may be found (1) in the abdominal 
cavity attached to the abdominal wall or (2) just inside the internal abdominal 
ring or (3), as is most common, in the inguinal canal or (4) just beyond it. 

The causes of such a malformation may be a short or abnormally attached 
gubernaculum, a contracted external ring, or an abnormally large epididymis. 

The diagnosis is made when the scrotum is found empty on the affected side, 
and a small movable tumor the size of a hazelnut is found in the inguinal region 
which gives the unpleasant testicular sensation on pressure. 

If no symptoms arise the best treatment is neglect; if, however, there is 
much pain or tenderness, which sometimes occurs when the testicle is in the 
canal, surgical intervention is required. The surgeon may succeed in drawing 
the testicle down into the scrotum or he may be obliged to replace it in the 
abdomen. 

If the testicle lies within the abdomen and develops there, its function is not 
interfered with. When it is subjected to constant pressure within the inguinal 
canal, such compression may hinder development or lead to atrophy. 

Differential Diagnosis of Swellings in the Inguinal Region. 

Swellings in the inguinal region are either fluctuating or non-fluetuat- 
ing. If fluctuation be present the tumor may be an abscess or a hydrocele. 
If an abscess be probable, there may be a history of vulvovaginitis, 
urethritis, scabies, or other irritant lesions about the genitals, and the 
patient will have some degree of increased temperature and a leukocytosis. 
Caries of the vertebra may produce a psoas abscess. If hydrocele is sus- 
pected, the history may show that the tumor has persisted since birth or that 
there has been an injury. The temperature and the blood count will be 
normal, and the light test will be positive. On percussion of a hydrocele or 
an abscess the note is dull and not tympanitic as it may be in hernia. A 
hydrocele with patent funicular process may recede under moderate pressure, 
but no gurgling is felt as in the reduction of hernial contents. 

In tumors without fluctuation, hernia, undescended testicle, or enlarged 
inguinal glands may be suspected. 

If the condition be hernia, the percussion note is resonant ; if reduc- 
ible, the tumor disappears quickly and is accompanied by a gurgling sound ; 
the external abdominal ring is patent and there is an impulse on crying or 
coughing ; there is opacity when tested by transmitted light. 

If the tumor is an undescended testicle, the corresponding side of the 
scrotum will be found empty ; the tumor is dull on percussion, freely mov- 
able, and hard. On pressure, the characteristic testicular sensations can be 
elicited in older boys. 



DISEASES OF THE GENITAL ORGANS. 453 

If the swelling is due to the presence of enlarged inguinal glands there 
will probably be an existing cause found in the genital region, such as eczema, 
vulvovaginitis, scabies, etc. Such tumors are dull on percussion, and hard 
and freely movable unless suppurating. In these cases the testicle will be 
found in its normal place. Enlarged glands are usually multiple. 

Frequently hernia and hydrocele occur simultaneously, and in such 
cases the diagnosis is more difficult. 



CHAPTEE XXXIII. 
DISEASES OF THE BLADDER. 

Cystitis. 

In infants, two forms are distinguishable, one presenting general symp- 
toms, including restlessness, anorexia, fever, pallor, and debility, but with- 
out urinary symptoms; the other with the above general picture, but with 
symptoms showing urinary involvement, such as increased frequency of 
urination, pain or difficulty in voiding, abdominal colic, tenderness over the 
bladder, and redness about the meatus. 

A frequent cause of cystitis is infection by the bacillus coli, either 
alone or in mixed infection, and such infections are termed colicystitis. 
Many other organisms are also found as the causative factor, but are of far 
less frequent occurrence. 

In colicystitis, the urine shows the following characters; it is turbid, 
acid in reaction, and contains albumin (usually less than 15/100 per cent.) 
pus-cells and bacteria, a pure culture of bacillus coli being frequently 
obtainable. The acid reaction of the urine in cases of cystitis signifies 
infection by the bacillus coli or the bacillus tuberculosis ; the latter is very 
rare as a primary infection, but does occur with general tuberculosis or when 
the kidneys or genitals are involved in tuberculous lesions. 

When due to infection by the pyogenes, the reaction is alkaline. In 
cases of such origin, the symptomatology is much the same as in colicystitis, 
but the disease is more severe. In pyogenic infections blood is often found 
in the urine. 

Treatment. — The remedy par excellence for cystitis is hexamethy- 
lenamin (urotropin) ; infants may be given two grains every four hours; 
older children 5 to 7-§ grains every four hours. Salol in smaller doses is 
also useful, but not quite as effective. Chronic cases may require irrigation 
of the bladder ; in such cases boric acid solution 1 per cent, or silver nitrate 
solution 1 in 5,000 are the best solutions to use. 

In all cases give plenty of alkaline waters to drink, avoid salty foods 
and spices, and keep the patient in bed while the acute symptoms persist. 

Vesical Spasm. 
Spasm of the sphincter muscle of the bladder often occurs in young children 
due to a varietv of causes; for example, dysentery, anal fissure, parasites in- 
flammations in the neighboring parts, as Pott's disease, and lesions in the rectum 
peMt or perineum. Occasionally in older children a brief spasm occurs due to 
certain drugs, such as turpentine, or to sudden exposure or local chilling as a 
cold closet The usual cause of spasm of the sphincter is the irritant effect of a 

454 



DISEASES OF THE BLADDER. 455 

highly acid or concentrated urine on the bladder walls. The most prominent 
symptom is frequent micturition, each act often yielding but a few drops of urine. 
Pain is severe and is accompanied by marked vesical and rectal tenesmus, but 
no blood is present in the urine. 

Treatment. — Treatment consists in the removal of the cause in conditions 
other than tbat due to the urine itself. When the spasm is due to the urine, the 
treatment consists in copious draughts of alkaline water and the administration 
of potassium acetate or citrate in doses of two to five grains with the tincture of 
belladonna or the tincture of hyoscyamus one to four drops every two or three 
hours. 

Vesical Calculus. 

The severest dysuria of the chronic type may be produced by a vesical 
calculus. Tbis condition rarely occurs in children, while in infants it is still 
less frequent. A sudden stopping of the stream of urine is the most characteristic 
symptom, although diurnal incontinence is occasionally the evidence which may 
call to mind the possibility of the presence of a calculus. Pain on urination often 
occurs and is usually felt in the end of the penis or in the perineum. Rectal 
tenesmus with prolapse is frequently present, due to straining when calculi exist. 
On account of the genital irritation in this condition masturbation is often prac- 
tised. Urinary changes differ from those in adults in that hematuria is rare, 
and pus and mucus are infrequent or occur in small quantities. A positive 
diagnosis is made when the stone is felt by bimanual rectal examination or by 
searching the bladder with a sound or wax-tipped catheter. 

The treatment is surgical. Removal through suprapubic incision is usually 
necessary. 



SECTION XIII. 
DISEASES OF THE NERVOUS SYSTEM. 



CHAPTER XXXIV. 

GENERAL NERVOUS DISEASES. 

General Consideration. 

To the unstable equilibrium of the rapidly developing brain, to its 
peculiar sensitiveness to peripheral irritation, to the important role played 
by the infectious diseases, the liability of the child to traumatism, and 
finally to hereditary influences, singly or combined with any of the above, 
must be attributed the many neurotic disorders which are peculiar to early 
life. 

A full and detailed history will be of great assistance in arriving at a 
diagnosis in this class of cases. A careful and complete physical examina- 
tion should be made with the child entirely naked. Trained observation for 
details coupled with logical reasoning will be required for success in many 
instances. Certain cases, if once seen in life, are rarely mistaken, as, for 
example, cretinism ; on the other hand, an unusual case of multiple neuritis 
may require a complete knowledge of the methods of examination, and the 
diagnosis will have to be supported by a differential diagnosis, consciously 
or unconsciously made by the physician. The sensory disturbances are 
elicited with difficulty in early life, and the muscle tone must be interpreted 
also from the view-point of the history of previous feeding. 

The gait should be carefully observed, as some are quite characteristie 
of certain groups of cases, for example, the cross-legged progression, or 
scissors position, indicates a spastic paraplegia. The spastic gait is seen in 
cerebral palsies, while the ataxic gait is assumed by children suffering with 
cerebellar disease, neuritis, or the more rare disease, hereditary ataxia. The 
swinging gait of poliomyelitis is distinguishable from the waddling, sway- 
ing gait seen in those with the various dystrophies. As the cooperation of 
the patient is not always obtainable, and the mother's statements may be 
innocently misleading, tests should be made for blindness and hearing. A 
candle or bright-colored objects may be presented to the eyes as a test. 
Vision may be tested with the cards described on page 538. The finger 
will be allowed to touch the eyeball in absolute blindness, but if the corneal 
reflex is present there will be prompt closure. An ophthalmoscopic exam- 

456 



GENERAL NERVOUS DISEASES. 457 

ination is feasible after proper preparation with atropin. Mummying the 
child as for intubation may be necessary with intractable children. It 
should be recollected that inequality of the pupils and even nystagmus mav 
be congenital. 

The hearing may be estimated by clapping the hands suddenly behind 
the child, by the use of a whistle, or the whispered voice. "Where an intel- 
ligent response may be expected the tuning-fork can be used. Tickling or 
pinching the toes or fingers may be used as a test for actual paralysis. It 
should be remembered that both upper extremities are rarely paralyzed in 
children : that the patellar reflex may be obscured by fatty deposits, and 
that it should be relied upon only after obtaining the same result after 
repeated tests. Ankle clonus, however, is always indicative of an abnormal 
condition. The superficial reflexes are of little or no value in the early 
years. The Babinski reflex, extension of the big toe, is of no significance in 
the first year of life, being normal during this period. 

When the electrical examination is made in children, great care should 
be employed not to frighten the patient; allowing them to play with the 
electrodes at first is a good plan. Use the mildest currents that will pro- 
duce results, and compare the reaction to the opposite extremity. The 
behavior of the muscle in reacting is often sufficient to appreciate degenera- 
tive changes. 

Paralysis in General. 

Paralysis or the loss of motor power may be associated with sensory 
and reflex disturbances and with atrophy of muscle. The motor inability 
may be localized and result in a monoplegia, that is. a paralysis of one 
extremity, diplegia in which both sides are involved, paraplegia in which 
the two lower limbs are paralyzed, and hemiplegia or a paralysis of one-half 
of the body. 

Again paralyses are spoken of as central when they are due to lesions 
of the brain. Spinal, when they originate in the cord; peripheral, when 
the result of nerve or muscle disease. 

General Characteristics of the Various Types — Cerebral Paralysis 
(Spastic Paraplegia). — This is commonly unilateral, the lesion being on 
the opposite side of the cortex: the face is partially involved. Spasticity, 
increased reflexes, slight electrical changes and no atrophy of muscle distin- 
guish this type. 

Spinal Paralysis. — Flaccidity with wasting of muscle indicates in- 
volvement of the peripheral motor neuron. There is no disturbance of 
sensation (except in myelitis). The reflexes are absent or diminished, and 
the reaction of degeneration is present. 



458 



DISEASES OE CHILDREN. 



Nerve Paralysis.-n The toxic forms are apt to be bilateral in distri- 
bution, the reflexes are lost and so also is muscle excitability. The trau- 
matic paralyses are due to pressure on the nerves, as a result of fracture, 
dislocation, and pressure from without. They are local in distribution, and 
if there is response to electrical stimuli the nerve recovers its function. 

Muscle Paralysis.— . The motor inability is here due to the changes 
in the muscle fibers themselves. There is diminished electrical reaction 
and atrophy or pseudohypertrophy of muscle. Diseases of the joints, bones, 
and tendons may by atrophy and disease produce a paralytic condition, as in 
rheumatoid arthritis. 




Fig. 134. — Volkman's ischemic paralysis, following fracture of the radius. 

Pseudoparalysis. — True paralysis may be simulated by muscle weak- 
ness, as in rachitis or chorea. Close observation and the electrical reaction 
easily distinguish the condition. 



Convulsions. 

{Eclampsia Infantum.) 

This symptom or symptom-complex results from a cerebral irritation 
producing a temporary unconsciousness, attended by irregular muscular 
contractions. 

The symptom in the infant and young child often corresponds to the 
chill of the adult. It is quite commonly observed because of the relatively 
greater excitability of the brain and the undeveloped power of inhibitory 
control. We may divide the causative factors into two groups — the reflex 
or functional and the organic. 



GENERAL NERVOUS DISEASES. 459 

Etiology. — The peripheral disturbances which may cause a convulsive 
seizure are many and various. The susceptible age is in the first two years 
of life. An apparently trivial cause, such as psychic or sensory impressions 
resulting from unusual excitement in a child with an inherited unstable 
equilibrium, may produce a typical seizure. Foreign bodies in the nose or 
ears, traumatism, intestinal parasites, preputial abnormalities, improper or 
indigestible articles of food, poisons, and the toxemias resulting from or 
preceding certain diseases, as rachitis, malaria, or tetany, are among the 
causes producing convulsions. Eachitis deserves special mention as an 
underlying predisposing cause because of the nervous instability it produces. 

The organic causes are meningeal hemorrhages at the time of birth, 
tumors of the brain, cerebral abscess, hydrocephalus, and the various forms 
of inflammation of the brain or its coverings. It should be recollected that 
regional as distinguished from general convulsions are indicative of organic 
lesions, and also that re ideated seizures over prolonged periods are character- 
istic of cortical disease. 

Description of the Symptom-complex. — The attack begins without 
warning. It may be preceded by slight twitching of the face and rolling 
of the eyes. There is then unconsciousness, the eyes are fixed and staring, 
tonic rigidity of the head, back, and extremities is shortly followed by clonic 
contractions of the facial muscles. These usually begin at the mouth, caus- 
ing grimaces and distortions of expression and some frothing. The teeth 
are firmly set. The color is dusky. In a general convulsion all the extrem- 
ities show clonic contractions and purposeless activity. The pupils are 
usually dilated and do not react to stimuli. The respirations are labored, 
affecting the pulse and causing irregularity of the heart action and increas- 
ing the cyanosis. There may be involuntary passage of urine and feces. 
After a variable time the muscular twitchings cease and the child passes from 
a coma into a deep sleep. The attacks may be and usually are shortly 
repeated unless influenced by treatment. After a period of sleep the child 
arouses and takes a normal interest in its surroundings ; it may then be 
considered free from the danger of another immediate attack. 

Prognosis. — This is usually good, but should be guarded until a defi- 
nite cause is established. It is always serious if the attacks occur in the 
new-born, in advanced childhood, or if they are unduly. prolonged and recur 
often. If convulsions usher in a disease they are not of as great prognostic 
importance as when they occur in the course of the disease. An exception 
to this statement must be made in cerebrospinal meningitis, in which initial 
convulsions are of bad omen. 

Differential Diagnosis. — The essential characteristics are temporary 
unconsciousness and irregular muscular contractions. 



460 DISEASES OF CHILDREN. 

In convulsions from organic causes, the regional involvement, often 
neuritis, and the resulting paralysis, may be distinguishing features. Epi- 
leptic seizures occur usually after the second year of life, they are apt to 
recur after longer periods and without an immediate causative factor. 
The history of predisposition may be obtained. 

Treatment. — First overcome the attack or symptom. Some one in 
the family will in all probability have given a mustard bath before the ar- 
rival of the doctor. If the attack persists inhalations of a few drops of 
chloroform may be given, and if there is any fever an ice-bag is placed to 
the head. Meanwhile a soap-suds enema is prepared and given on general 
principles. If there is an elevation of temperature, the enema may be given 
cool at 70° F. Examine the fecal discharge for a possible etiological factor 
as some foreign substance ingested or for intestinal parasites. Keep the 
room noiseless. Follow the enema by a rectal injection of the bromid of 
soda grains ten, and chloral hydrate grains three, for a five-year-old child, 
if the twitching still persists. When the child can swallow, calomel or 
castor oil is given to rid the intestinal canal of possible toxins. 

In the period of quiescence obtain a careful history, make a detailed 
examination and, arriving at a diagnosis, order such treatment as is suited 
to the underlying cause, as, for example, a properly balanced diet, with 
sufficient proteins and fats for rachitis. 

Chorea. 

(St. Vitus' Dance; Sydenham's Chorea; Chorea Minor.) 

Chorea is a neurotic affection, characterized by purposeless movements 
of various parts of the body. 

Etiology. — i Girls are more often affected than boys. It appears most 
frequently from the fifth to the twelfth years of life. Eheumatism and ton- 
sillitis are antecedent causes. It may develop as a result of fright, excessive 
school duties, intestinal autointoxications, or imitation of other choreic 
children. The offspring of neurotic parents are especially predisposed. 

Pathology. — The theory that rheumatism, chorea, and endocarditis 
are related in many instances is gaining ground, and is certainly clinically 
of value. The toxin of rheumatism may affect the heart or the cortex of 
the brain in the Eolandic area, and causing irritation produce the character- 
istic movements seen in chorea. 

Hypertrophied tonsils and valvular disease are not infrequently asso- 
ciated with chorea. The infectious theory is held by the majority of path- 
ologists to-day, and these same observers believe in the infectious character 
of rheumatism and endocarditis. 



GENERAL NERVOUS DISEASES. 461 

Symptomatology. — The symptoms usually come on insidiously, and 
may not be noticed until quite marked. The child is chided for carelessness 
or awkwardness in dropping articles or for unnecessarily fidget-ting. Ner- 
vousness and irritability of temper are noticeable. Upon little or no provo- 
cation the child begins to cry. The muscles in various parts of the body 
later begin to twitch and contract, the face making ludicrous grimaces. 
These movements are entirely involuntary, and if the examiner fixes the 
child's attention, these irregular movements are exaggerated. In the early 
stages the body movements may be slight, and are best felt when the child's 
hands are placed within those of the examiner and the arms put on a slight 
tension. The tongue also, when closely observed, shows the twitching move- 
ments quite early in the disease. During sleep the movements cease. Fol- 
lowing a severe fright or chastisement chorea may suddenly develop with 
well-marked symptoms. Aggravated cases or those under no control are 
often pitiably affected : the child cannot dress or feed itself ; sleep is dis- 
turbed; speech is altered and may be so changed as to be unintelligible. 
Pseudoparalysis, due to muscular weakness, may occur, but the extremity is 
never completely at rest for any length of time. On the other hand, a case 
recently under our observation in the Post-Graduate Hospital had such 
marked jactations that she had to be fastened in bed and fed by gavage 
until relief of symptoms was obtained by medication. 

Hemichorea. in which the movements are confined to one side, is some- 
times seen, and in these cases sensation is somewhat impaired on the same 
side. 

There is no elevation of temperature, unless the case is complicated 
with rheumatism or endocarditis. It is not uncommon to find a mitral 
regurgitant murmur develop during the attack. Sometimes, in fact, it may 
precede it. Functional or anemic murmurs are heard in prolonged cases. 

Course and Prognosis. — Chorea is in itself almost never fatal. Un- 
complicated cases tend to recover in from one to several months. Ten 
weeks is the duration in the average case, but relapses are frequent. 

Diagnosis.— This is, as a rule, quite simple, resting upon the char- 
acteristic muscular movements and especially the abnormal movements of 
the tongue. Imitative choreic movements are distinguished by their short 
duration, while in hysterical chorea the harmonious character of the move- 
ments and other hysterical phenomena serve to distinguish the neurosis. 
Sachs calls attention to the fact that choreic movements may be associated 
with infantile cerebral palsies and must be distinguished from true chorea. 
Spasticity and the increased reflexes should here put the examiner on the 
risrht track. 



462 DISEASES OE CHILDREN. 

Complications. — Acute or subacute rheumatism, and heart disease, 
are the most frequent complications. 

Treatment. — The treatment differs for the mild and severe cases. 

Mild Cases. — Eest is the first and most important measure, as without 
it all treatment is unsatisfactory. The child should be immediately re- 
moved from school. By rest is here meant avoidance of all mental excite- 
ment or effort ; physical rest being obtained by putting the child to bed in 
a well-ventilated room, and keeping it there until the coarser movements 
cease, when the child may be allowed up for a half -hour in the same room, 
and this allowance increased from time to time if good progress is made. 
Toys which require no mental effort on the part of the child are allowed, 
while reading and singing to the patient by the attendant serves to shorten 
the enforced rest. Visitors and the other members of the family are to be 
excluded. The diet must be carefully supervised. Milk alone for a few 
days and later cereals and vegetables, eggs and butter are allowed. Alcohol 
sponge baths or brine baths for their tonic effect may be given daily. 
Arsenic in the form of Fowler's solution is given as an adjuvant, but should 
not be depended upon to cure the patient without the rest treatment, as it is 
far from being a specific. Begin with three drops three times a day for a 
five-year-old child and increase gradually by one drop up to thirty drops 
daily. The arsenic should be administered after meals, well diluted in 
some alkaline water. It must be stopped if there is any nausea or pumness 
of the eye-lids. In rheumatic cases novaspirin or the salicylate of soda may 
be given in conjunction with the above treatment. 

Severe Cases. — 'The rest cure is imperative. A padded bed is some- 
times necessary. The movements should be quickly controlled by doses of 
the bromids with chloral per os or per rectum, and then the arsenic treat- 
ment may be begun. If the chloral and bromids are not sufficient to control 
the jactations, a hypodermatic dose of hyoscin hydrobromate grains 1/200 
for a five-year-old child will do so. This should not be used if there is any 
heart involvement. Veronal, grains 3, at night, will promote sleep if there 
is insomnia. Feeding through a tube must occasionally be practised. It is 
best to order a certain fixed amount of nourishment to be taken or fed 
during the day. If rheumatic arthrites complicates the disease, large doses 
of salicylates, up to 45 grains a day, may be given by rectum in a starch 
enema. 

Convalescence. — School duties should be abandoned for some months. 
Life in the country, at the seaside, or in a suburban town, is advisable. 
Baths, iron tonics, and nutritious diet, including the fats and meats, are 
now indicated, for profound anemias are often concurrent with chorea and 



GENERAL NERVOUS DISEASES. 463 

lead to relapses unless corrected. School life must not be resumed until 
such time as the possibility of a recurrence is well past. Enlarged tonsils 
should be removed. 

Forms of Chorea. — Choreiform affections or movements are practi- 
cally synonymous with habit-spasms and tics. (See page 473.) Hunt- 
ington's chorea or hereditary chorea is a rare disease of a chronic nature 
and occurs in later life. 

Chorea insaniens is a fatal form, which may be due to a bacteremia. 
Chorea major is a hysterical chorea under which are included several groups 
described mainly by German writers ; for example, chorea electrica. 

Hysteria. 

True hysteria is a rare disease of early life, and is usually seen in chil- 
dren of the school age, especially in girls at puberty. 

Etiology. — Heredity is an important factor, for if one or both parents 
are neurotic there is likely to be little or no control over the offspring ; they 
are indulged in every whim, and too much attention is paid to minor ail- 
ments, and the imitative disposition of the child is often the precursor of 
real trouble. Children in institutions and asylums who receive only little 
personal attention from their superiors are often the victims of hysteria. 
Morbid sensations and psychical phenomena, such as fear, are productive of 
attacks. 

Symptomatology. — The attacks do not present any great variation 
from those seen in adults. The tendon reflexes are not so often found 
exaggerated and disturbances of sensation are not commonly observed. It 
would be impossible to describe a typical case of hysteria, as certain groups 
of symptoms are in evidence in one case and entirely absent in another. 
The symptoms are traceable to defects in the various body functions, symp- 
toms, and organs. 

Sachs classifies the symptoms into three groups — psychic, motor, and 
sensory manifestations connected with vasomotor disturbances. 

Under the first group are the weak-minded children with a perverse 
will. Hysterical mania may manifest itself if the child's wish is opposed, 
following a sudden fright or even a fit of anger. Alternate laughing and 
crying, with kicking or tearing of objects and clothes, occur, while the dis- 
turbance is made worse by attempts to console or sympathize. Hystero- 
epilepsv, while undoubtedly extremely rare in children, is of greater im- 
portance than some of the other hysterical manifestations. These children 
have a vicious family history, including alcoholism, insanity, etc. The 
attacks must be studied and epilepsy excluded after repeated observations. 
In hysteroepilepsy there is no aura. The bladder and rectal functions are 



464 DISEASES OE CHILDREN. 

not disturbed, the attacks are of longer duration, there is no complete loss 
of consciousness, personal injury is rare, and the movements themselves are 
tonic, exaggerated, and often purposeful. 

A great variety of hysterical manifestations may be seen : those involv- 
ing only the lower extremity or the head and neck alone. The esophageal 
spasm is not rare in girls at puberty (globus hystericus). 

Sometimes paralysis follows the jactations or occurs alone as a hyster- 
ical manifestation. Again, only certain functions may be paralyzed. 
ETysterical aphonia is not uncommon, especially in institutions and asylums. 
They disappear quite suddenly when confidence is established, and local 
examination reveals a normal laryngoscopic picture. Any part or portion 
of the body may be affected. The regional paralysis is, moreover, usually 
associated with regional anesthesia. The condition of the reflexes which 
are not exaggerated and the absence of spasticity in the muscles and the 
unaltered electrical reaction serve to differentiate it from the true forms. 
Spasmodic conditions, such as hiccough, dysphagia, anorexia, and vomiting, 
sometimes occur and may be extremely troublesome. Spasmodic cough and 
purposeless screaming are especially seen in young girls. Hyperesthesia 
and anesthesia are not so commonly observed as in adults, but when present 
are apt to distort the diagnosis if the physician is not on his guard. Dis- 
turbances of vision especially must be kept in mind in this relation. Organic 
lesions, however, should be carefully excluded before a diagnosis of hysteria 
is made. 

Prognosis. — This is better in children than in adults. Eelapses are 
common if control is not absolute. 

Treatment. — The acute attack may often be interrupted in children 
in the ordinary case by the use of the aromatic spirits of ammonia, not too 
well diluted, or by giving apomorphin in emetic doses. Cold douches, when 
unexpectedly applied to the face and chest, may arrest the attack. In in- 
tractable cases the rest treatment should be faithfully tried. If this is not 
effective a change of environment is then most important. The neurotic 
parent influences the child not only through the inherently weak nervous 
system, but by improper training and defective example. Sometimes it is 
necessary to send these children to special schools whose principals have 
made a study of neurotic children. Improvement in general physique is 
always to be aimed at and is attained by aerotherapy and nutritious plain 
food. The dietary should be supervised and a special list prepared for the 
needs of the particular child. 

The suggestive influence of the physician who will exert his force of 
character and thus establish confidence can be made extremely powerful in 



GENERAL NERVOUS DISEASES. 465 

its effect, and often produce a cure alone. Baths and douches have a dis- 
tinctly favorable influence. The electrical currents are sometimes useful 
for their moral effect. Medicinal measures are rarely necessary if the above 
plan is feasible and strictly adhered to. 

Epilepsy. 

Epilepsy is a disease often occurring in early life, and characterized by 
seizures which vary in their intensity, affecting only a portion of the body, 
or they are generalized. 

Etiology. — The children of neurotic parents, those who have them- 
selves been afflicted with epilepsy, hysteria, chorea, and similar nervous dis- 
eases, may fall victims to this disease. To these may be added syphilis and 
alcoholism. Traumatism during or after birth and maldevelopment of the 
brain as a result of acute infective processes may later lead to epileptic 
seizures. 

Among the exciting causes the intestinal toxemias, visual defects and 
obstructive growths in the respiratory tract, such as adenoids and polypi, 
may be mentioned. 

Symptomatology. Petit Mai. — . In this form there may at intervals 
occur momentary periods of unconsciousness. The child may suddenly 
cease playing or speaking and stare into vacancy. The pavents may bring 
the child to the physician complaining of its " fainting attacks." If ques- 
tioned, the child has no recollection or knowledge of these periods. If seen 
at the time of an attack, the pupils of the eyes may be seen to suddenly 
dilate and the face turn pale. Occasionally there is a period of drowsiness 
or the child seems dazed and is not willing to immediately resume its former 
occupation. 

Grand Mai. — There is no sharp limit between the mild and the severe 
forms. Grand mal is spoken of if there is an aura, a period of unconscious- 
ness, a convulsion, and the involuntary passage of urine and feces. It 
should be recollected that young children may not have an aura or may be 
incapable of interpreting it. Intelligent parents may sometimes foresee a 
coming attack by noting a change in the child's disposition or by observing 
certain unusual bodily movements. The sensation may be felt in different 
situations, as the stomach, the eyes, or various noises or sounds are heard in 
the ears. 

The child suddenly falls into unconsciousness and a convulsive seizure 
takes place simulating the ordinary eclamptic seizures described on page 
458. Sometimes an initial cry precedes the fall. The dilated pupils do not 
react to light, the tongue may be bitten, and blood-stained saliva may appear 
at the mouth, although this is not usual in childhood. After a few minutes 
30 



466 DISEASES OF CHILDREN". 

the spasm relaxes and the patient is found to have involuntarily passed his 
urine or even emptied the rectum. Following the return to consciousness 
the patient is in a semicomatose or stupid condition, complains of headache, 
and often drops into restless sleep. Nocturnal attacks may be discovered 
only by the bitten tongue or drowsiness on the succeeding day. The 
" epileptic voice sign " of Clark and Scripture should excite suspicion in 
the medical attendant. It is described as a monotonous voice, the melody 
proceeding by even steps, and occurs in this disease alone. 

Diagnosis. — Hysteria is differentiated from epilepsy by the absence 
of entire loss of consciousness, the stage of excitation with laughing and 
crying, and by the absence of dilated pupils and involuntary urination and 
defecation. Tumors of the brain may affect localized regions; they may 
have peculiarities of gait and changes in the fundus of the eye. 

Prognosis. — The gravity is determined to a great extent by the age. 
The earlier the seizures appear the poorer the prognosis. Frequent recur- 
rences of well-marked attacks are less hopeful and may be followed by 
feeble-mindedness. 

Treatment. — During the attack the child should be placed in bed and 
guarded against personal injury. Little or no food should be offered after 
the attack until the period of drowsiness is past. The diagnosis once estab- 
lished, stringent prophylactic measures should be instituted to prevent re- 
currences. A life in a quiet country district, with an unusual amount of 
sleep and little mental exercise, is distinctly beneficial. A diet consisting of 
simple food (coffee and tea being absolutely excluded), with plenty of vege- 
tables and fresh fruits to insure daily bowel activity, is required. For the 
children of the poor, life in the epileptic colonies, where the children con- 
form to a certain routine, adds much to their chances of improvement. 

The bromids, when administered in divided doses, five grains for a 
five-year-old child three or four times a day, while not curative, serve to 
reduce the number of attacks. When the latter occur at night only, it is 
best to administer one large dose, about twenty grains, at bedtime. This 
drug should be given to the point of toleration and resumed after a period 
of rest. 

Headaches. 

Headache is a symptom deserving of especial attention, since it may be 
symptomatic of many functional or even organic disorders. 

Etiology. — It most frequently results among children from gastric 
or intestinal disturbances and from eye-strain. Anemic children who have 
been improperly fed and who are forced into competition with their school- 
mates often suffer from toxic headaches. If the child remains in badly 
ventilated or superheated rooms frontal headaches frequently result. The 



GENERAL NERVOUS DISEASES. 467 

cause may be more obscure and may be found to result directly or indirectly 
from adenoids, ear disease, nephritis, cardiac disease, and malarial poison- 
ing. Young girls at the beginning of the menstrual period, especially if 
they are neurasthenic, may complain of frequent headaches. Many of the 
acute infectious diseases are preceded by cephalgia as a prodromal symptom. 
Meningitis and tumors of the brain cause persistent headaches which are 
referred to one area. 

Migraine or sick headache occurs in older children. It is usually 
unilateral in character and preceded by nausea and vomiting and 
disturbances of vision. 

Diagnosis. — The diagnosis depends upon a careful physical exami- 
nation to exclude organic disease, and in obscure cases of this type lumbar 
puncture, the opthalmoscope and the tuberculin tests may be necessary. 
Functional headaches when dependent upon intestinal derangements are 
accompanied by a coated tongue, a fetid breath, and constipation. Those 
due to anemia and general asthenia exhibit pallor of the mucous membranes, 
lassitude, and depression. In these cases a blood examination, at least the 
Talquist hemoglobin estimation, should be made. Headaches due to visual 
errors begin, or are intensified, at the end of the school day or whenever 
the eyes have been overtaxed. An examination with the test cards (see 
p. 538) should be made as a matter of routine, as a more detailed ocular 
examination may then disclose astigmatism or other refractive errors. 

The diagnosis of migraine depends upon the periodic unilateral attacks 
and the accompanying nausea and eye disturbances. 

Treatment. — This is directly dependent upon the cause. "When the 
headache is the result of digestive errors acute attacks may be relieved by 
clearing out the intestinal tract and prescribing a proper dietary which is 
to be strictly followed. Anemic headaches are cured by life in the open 
air or at least an abundance of fresh air and sunshine in the rooms which 
the child occupies. Eeducing the number of study hours and prohibiting 
special studies after school may alone be sufficient. Obstructions in the 
respiratorv tract and errors of refraction must be removed before any 
progress can be made. 

A child suffering with migraine should be put to bed in a quiet, dark 
room, during the attack, and analgesics, as phenacetin combined with 
caffein or the bromids, may be given. A hot-water bag or light massage 
over the forehead and temporal regions may be agreeable. Future attacks 
must be prevented by strict regulation of the child's life and diet. 



468 DISEASES OF CHILDREN. 

Insomnia. 

This symptom which occurs in infancy and childhood generally results 
from some functional derangement which can usually be removed when 
once recognized. 

The infant and child are dependent upon a sufficient amount of sleep 
to promote healthy growth. That it cannot or does not spend sufficient 
hours in sleep may be due to acute physical discomfort or from a perversion 
of its natural habits resulting from mismanagement on the part of its 
attendants. 

The following table will give a general idea of the daily amount of 
sleep required in early life: 

Healthy new-born, 20 hours, minimum 16 hours. 

Six months, 16 hours (2 naps). 

One to three years, 12 hours (and one nap). 

Three to six years, 10-12 hours. 

Six to ten years, 8-10 hours. 

When the infant is unable to approximate the normal amount of sleep 
a careful examination of its mode of life should be made followed by a 
systematic physical examination. Among the more frequent causes of 
sleeplessness are digestive disturbances, undue excitement, bad hygienic 
conditions, and localized pain. Physical examination may show that the 
child is suffering from an otitis, skin lesions, enlarged tonsils, adenoids, 
rachitis, extreme anemia, or the disease may be organic, such as meningitis 
or incipient disease of the brain or spinal cord. 

Treatment. — When the cause is found efforts should be made to 
remove or correct it before any other measures are undertaken. A careful 
regulation must be made of the child's daily life, not omitting what may 
seem to be minor influences bearing upon its sleeplessness. A well-venti- 
lated, cool, darkened room should be provided, which the infant or child 
should occupy alone; the bed clothing should be light and not too warm. 
The evening meal must be simple, not containing too much liquid. Bead- 
ing of exciting stories to children should be prohibited. These changes 
with an outdoor life are often sufficient to correct insomnia. 

If a high temperature is the cause of the insomnia, baths or sponging 
with alcohol will often promote sleep. If temporarily any of the hypnotics 
are necessary, the bromids, in doses of one and a half grains for each year 
of age, or one grain of veronal for a two-year-old child, will produce the 
desired effect. The bromids combined with chloral hydrate are effective 
in older neurotic children, especially if they also have night terrors. 



GENERAL NERVOUS DISEASES. 469 

Pavor Nocturnus. 
(Night Terrors.) 

This condition occurs in children who have in some manner unduly excited 
their nervous system. They may or may not he the children of neurotic parents. 
Children from the third to the eighth year are more commonly subject to night 
terrors. In our experience the condition appears with the greatest frequency at 
the beginning of school life when unaccustomed responsibilities must suddenly be 
assumed. The reading of unnatural stories so often practised by nurses or 
unusual and grotesque sights, as in the circus, may induce an attack. A heavy 
meal just before retiring may also be a cause. 

The children awake suddenly, usually before the midnight hour, and cry out, 
exhibiting signs of fright or terror. They are soothed with difficulty and can 
give no explanation of their sudden awakening or dream. If questioned in the 
morning they remember nothing of the occurrence. The terrors may repeat 
themselves several times in a week, but they seldom occur twice in the same 
night. When the cause is removed the recurrences become more infrequent and 
finally disappear altogether. 




Fig. 135. — Tetany, with characteristic positions of hands and feet 

Treatment. — Every effort should be made to decrease the nervous excitabil- 
ity of the child by prohibiting school work <at all for a time or decreasing the 
number of school hours. At home no supplementary teaching should be aliowed 
and association with older minds not encouraged. A healthy amount of physical 
tire, rather than mental strain, should be the desideratum. The evening meal 
particularly should consist of light and easily digestible articles, and should be 
eaten at least an hour before retiring. If these measures are carried out it will 
rarely be necessary to give bromids or hypnotics. 

Tetany. 
(Tetanilla; . I rth rogryposis.) 

Tetany is a neurotic disorder characterized by intermittent or constant 
tonic spasms of the muscles of the upper and lower extremities. 

Etiology. — The disorder is dependent upon the absorption of toxic 
products which readily affect the highly sensitive nervous system of early 
life. It occurs most frequently from the sixth month to the end of the 



470 



DISEASES OF CHILDREN - . 



second year. We would give rachitis the first place in the role of etiologic 
factors, and the conditions which may produce this disease may also pro- 
duce tetany. This is further borne out by the fact that convulsions and 
laryngismus stridulus frequently occur in those subject to tetany. It also 
results from intestinal or peripheral irritation and may follow exhausting 
diseases or secondary pneumonias. 

Defective parathyroid matabolism is believed to be an underlying cause 
of this and similar spasmophilic conditions. With this MacCallum asso- 
ciated defective calcium metabolism and treatment has been based on this 
deficiency. It also follows exhausting cases of measles, pertussis and 




Fig. 136. — The face in tetany. 



typhoid fever. Peripheral nerve excitability is always present. An 
ennervated muscle group responds to both cathodal and anodal closing 
contractions when less than five milliamperes of current are used. 

Symptomatology. — The condition begins without any warning in 
infancy, although older children sometimes complain or give evidence of 
an itching or tingling sensation. Attention is generally called to the con- 
dition by the muscular contractions of the hands and feet. A close exami- 
nation will show that the arms are held quite closely to the chest, the fore- 
arms being partly flexed on the arms and the hand flexed at the wrist, 
while the fingers may either be tightly closed over the inverted thumb on the 
palm, simulating the driving position, or they may be hyperextended and 



GENERAL NERVOUS DISEASES. 



471 



held closely together like the obstetric hand. In the lower extremities the 
thighs may be drawn up onto the abdomen and the legs flexed on the thighs ; 
some degree of adduction of the thighs is generally present. The foot itself 
is extended or hyperextended, and the toes are flexed. The position of 
talipes equinovarus being often assumed. We have also noted spasticity of 
the erector-spinae group of muscles, so that the child could be raised by 
the head retaining an erect posture. The child's expression is one of dis- 
comfort. Pain is elicited if attempts are made to replace the extremities 
in their natural positions. There is rarely any temperature which can be 




Fig. 137. — Pseudo tetany, characterized by trismus, and marked spasm 
of muscles; uninvolvement of upper extremity; mentality unimpaired. 



attributed to the condition itself and the mentality is not affected. After 
a variable time, sometimes a few days or it may be weeks, the contractures 
intermit and the so-called latent period may be entered into, in which there 
is weakness and some slight spasticity of the affected muscle groups, or the 
symptoms may never return. In this disease certain phenomena may be 
elicited which are distinctly helpful in making or confirming a diagnosis. 
Trousseau's symptom can be produced in the latent period by pressing 
upon the main nerves and arteries of the extremities. In thi< way a char- 
acteristic paroxysm can be produced which ceases when the pressure is 
removed. 



472 DISEASES OF CHILDKEN". 

Erb's symptom is dependent upon the increased electrical excitability 
in the peripheral nerves, muscular contractions being produced even by 
weak currents. 

ChvosteVs symptom is a facial phenomenon which is of value if 
obtained in conjunction with the others and is elicited by pressing the finger 
or any other blunt object over the facial nerve or tapping smartly over the 
exit of the nerve when contractions immediately occur of the enervated 
muscles. 

Differential Diagnosis. — From tetanus it may be distinguished by 
the absence of trismus which is an early symptom, by the lack of fever, by 
the intermittent attacks, and the ability to elicit Trousseau's, Erb's and 
Chvostek's signs. Cerebrospinal meningitis is distinguished by the presence 
of high irregular temperature, cerebral signs, and by lumbar puncture. 

Prognosis. — The prognosis is mainly dependent upon the underlying 
cause. In itself it rarely endangers life except by predisposing to 
convulsive seizures. Relapses are not uncommon, especially in those cases 
due to nutritional disturbances. 

Treatment. — The underlying condition must be carefully sought for 
and treatment immediately directed toward its removal. It is a safe rule 
to thoroughly empty the bowels by the use of a large dose of castor oil or 
calomel. An enema may be given for immediate relief. The stools should 
be kept for the physician's examination, as he may therein find the source 
of the peripheral irritation, such as badly digested food or intestinal para- 
sites. Baths at a temperature of 110° F. may be given two or three times 
during the day for their relaxing effect. In severe cases a mixture of 
chloral hydrate and the bromid of soda can be injected into the rectum. 
In the latent period dietetic measures should be coupled with most favorable 
hygienic conditions. The food ordered must be such as to overcome the 
rachitic manifestations if present (see p. 413), or to produce an increase in 
weight if the neurosis has resulted from an exhausting disease. Calcium 
lactate 2-5 grains three times a day, may be given to supply calcium 
deficiency. 

Myotonia Congenita. 
{Thomson's Disease.) 

Myotonia congenita ds a rare disease, mainly hereditary, characterized by 
a sudden rigidity of certain muscle groups when a voluntary movement is at- 
tempted. 

Etiology. — The disease may occur early in childhood, but the greatest num- 
ber of cases are seen between the fifteenth and twenty-fifth year. Thomsen 
believes it to be a hereditary disease ; five generations in his own family having 
been so afflicted. Inclement, cold weather and emotional states may bring on 
the attacks. 

Symptomatology. — The muscular contractions develop when the patient 
attempts some voluntary act, as rising from bed or from a chair. The muscular 



GENERAL NERVOUS DISEASES. 473 

spasm prevents the completion of this effort, and repeated attempts are necessary 
before it is accomplished. These inhibited efforts in a child otherwise well 
developed are striking enough to fix the diagnosis. If a sharp blow is given over 
a muscle, a tonic contraction occurs which persists for some time. Erb has 
shown that the muscles react peculiarly to electrical stimuli. This " myotonic 
reaction," as he calls it, is a valuable confirmatory sign. Faradic currents stim- 
ulate the muscles, producing wavy, rythmical long-continued contractions. The 
same effect may be produced by the galvanic current. 

Diagnosis. — The disease is distinguished from tetany by the contractions 
produced by mechanical stimulation and by the peculiar electrical reaction (Erb's 
myotonic reaction). Furthermore, there is no increase in mechanical excitability 
by pressure over the nerve or vessel trunks as in tetany. Congenital paramyotonia 
(Eulenberg's modification) may be differentiated by the absence of the myotonic 
electric reaction and also of any increase in the mechanical excitability. 

Treatment. — Thomsen noted that the symptoms appeared less often the 
greater the muscular activity of the patient ; he therefore advised a life which 
would necessitate a constant use of the muscles. 

Paramyoclonus Multiplex. 

This disease, although very rare in early life, is mentioned here mainly for 
the purposes of differential diagnosis. It is characterized by the production of 
repeated momentary clonic spasms affecting a certain muscle or groups of muscles 
which are usually symmetrically involved. The muscles of the face are rarely 
involved. A slight tremor of the muscles may be observed between the attacks 
which usually follow some strong emotional excitement or physical effort. 

The myotonic reaction is rarely increased and no change in electrical 
excitability is noticed. 

Treatment. — We are almost powerless to effect a cure in this disease, al- 
though amelioration of the symptoms is possible by the use of sedative baths, 
mild gymnastic exercises, and a life free from excitement. 

Angioneurotic Edema. 

(Acute Circumscribed Edema.) 

This is a vasomotor disturbance, trophic in origin, characterized by attacks 
of circumscribed edematous areas on the body. 

Gastrointestinal intoxication is the most frequent cause in children, although 
it sometimes appears without any discoverable reason. The edema may be well- 
marked a few hours after its inception and may just as suddenly disappear, only 
to reappear in some other portion of the body. There are no marked constitu- 
tional symptoms, the children simply complaining of the itching or the discomfort 
caused by the edema when it affects, for example, the face. 

In a case seen by one of us there were unquestionable signs of edema of the 
lungs, which appeared suddenly, and cleared up within forty-eight hours. The 
area affected is raised, pale in the center, with an irregular bluish-red margin, 
differing from the other edemas in that it does not pit on pressure. Fatal cases 
have been reported in which the larynx and pharynx were affected. 

Treatment. — Special treatment during the attack is hardly necessary. Com- 
presses wrung out of warm boric acid solution are soothing to the patient. A 
saline purge should be given and future attacks inhibited by scrupulous attention 
to the dietary. 

Tics. 

A tic is the unconscious activity of a group of voluntary muscles 
resembling a purposeful movement, its frequent repetition classing it as a 
habit. 



474 DISEASES OF CHILDREN. 

They occur most frequently in children from the fifth to the four- 
teenth year of life. An underlying neurotic element can usually be found 
in the patient or he has been trained under attendants who by their man- 
agement have not developed his self-control. These neurasthenic children 
may easily develop a tic from some primary source of irritation, as foreign 
objects or growths in the air passages or eyes, skin diseases, phimosis, or 
even chorea. They may arise from emotional disturbances or as a result of 
imitation, as pointed out by Scripture, in children of unstable and willful 
disposition. The most common tic is the one involving the muscles about 
the eye in which the child rapidly winks the eye-lid several times in suc- 
cession. This occurs at short intervals during the day. Not unlike these 
in motor characteristics are the tics affecting the face, scalp, ears, tongue, 
neck, and extremities. When tics are accompanied by mental disturbances, 
a child otherwise rational may repeat words or phrases of an obscene char- 
acter without provocation or regard to the time and place. This is known 
as coprolalia. 

Differential Diagnosis.—- Tics may be distinguished from chorea by 
the purposive, systematic nature of the movements which occur at intervals. 
The spasms of paramyoclonus multiplex affect only a certain muscle and 
are not controlled by fixing the attention. Habit spasms resemble normal 
movements, but differ from them in that they are unnecessary. They are 
unlike tics in that they are not convulsive in type. 

Stuttering and Stammering (Hyperphonia.) — In this connection 
another class of tics forming a large part of the speech defects of childhood 
may be considered. Scripture defines hyperphonia as a psychomotor rieuro- 
sis or a mental tic or habit over which the patient has no control and 
which is the result of a compulsive idea connected with speaking. A 
neurotic child may acquire the habit by imitating others or he may have 
some defect connected with his respiratory apparatus. 

The symptoms have been divided into spasms and hypertonicity, affect- 
ing the respiratory, laryngeal, and articulatory muscles; to these are 
sometimes added facial and bodily tics. 

Treatment. — A careful physical examination, including the special 
organs, and an inquiry into the details of the child's life should be made 
in every case. An underlying and neglected "cause may be found m 
refractive errors, abnormalities in the nose, ears, or teeth. Peripheral irri- 
tation from any source must be removed. While this is not curative, it is 
conducive to a more rapid recovery and prevents recurrences. The physical 
condition of the child should be improved by nutritious food, tonic baths, 
ample amount of sleep, and a routine life under judicious discipline. A 
change of environment will often make the special treatment much more 



GENERAL NERVOUS DISEASES. 475 

effective. Fowler's solution may often be given with benefit. In a num- 
ber of our cases the method advocated by Scripture was remarkably effective.. 
It depends upon the voluntary imitation of his own act by which the child 
is trained to a conscious performance of the tic. In this way he is encour- 
aged and enabled finally to inhibit the act. The child looks into a mirror 
and is directed to imitate five times in succession his own tic when it 
appears. At first the imitation is a poor one, but improves with practice, 
until finally complete control is obtained. 

Scripture's method for stuttering and stammering consists in intro- 
ducing melody into the monotone voice of the stutterer. The child is 
directed to repeatedly sing a line of some familiar song; he is then taught 
to speak a sentence in the same sing-song fashion. In this way the mono- 
tone voice is finally abandoned and cadences and inflections are introduced. 
The " melody cure " is founded upon the fact that a stutterer never stutters 
when he sings. This simple treatment is elaborated by encouraging the 
child in forms of elocution and graceful mannerisms. 

Finally, in some cases it is also necessary to distract the mind when 
the patient starts to speak; this is done by teaching him to beat time in a 
quick, vigorous manner as he starts to speak or to set himself off by repeating 
one, two, and starting off to speak on three. These lessons are given at 
first three times a week for half-hour periods, the time and interval being 
lessened as progress is made. 



CHAPTER XXXV. 
DISEASES OF THE PERIPHERAL NERVES. 

Multiple Neuritis. 

Definition. — An inflammation of the peripheral nerves, in some of 
which there is a tendency to acute degenerative changes. It may affect 
several nerves, usually symmetrically, or it may be general. 

Etiology. — Bacteria or at least bacterial toxins in all probability 
cause the disease. The infectious diseases, especially measles, malaria, 
influenza, typhoid, and tuberculosis, may be followed by a polyneuritis, but 
it is a rare complication, with the exception of diphtheria. Sometimes 
exposure or cold and rarely alcohol, arsenic, or lead cause the disease. 
Alcohol must be considered as a factor in treating the children of our 
foreign population. 

Pathology. — There is an inflammation of the affected nerve, inter- 
stitial or parenchymatous in character, followed by more or less complete 
degeneration of the fibers. The appearance of the nerve at first is that 
of an acute inflammatory nature, with swelling, hyperemia, and minute 
hemorrhages in the nerve sheaths. Later degenerative changes in the nerve 
fibers only are seen. The muscles undergo parenchymatous or even 
interstitial changes. 

Symptomatology. — The onset may be sudden, with a chill or a con- 
vulsion and fever; as a rule, however, it is gradual. The mother may 
notice that the child is unable to properly support itself on its feet; if 
forced attempts to walk are made the child stumbles or sinks to the floor. 
After a few days or sometimes within a few hours there is intense pain on 
handling. The child cries when approached, fearing the pain of motion. 
Occasionally the sensitiveness along the course of the nerve may be elicited. 
Paralysis now follows the muscular weakness and it progresses symmetri- 
cally. The child may continually moan or cry out with the pain, but does 
not refuse its food. Foot-drop and wrist-drop develop, and the muscular 
contractions may cause deformities. Tendon reflexes are abolished alto- 
gether, or at least diminished, and the reaction to the galvanic current is 
slow. Muscular atrophy develops, but is not marked. 

Diagnosis. — The history of an antecedent disease or a distinct causal 
factor, as alcohol, may be suggestive when pain and paralysis ensue. The 
association of motor and sensory symptoms or paralysis along anatomical 
lines and the changed electrical reaction should cause no confusion. When 

476 



DISEASES OF THE PERIPHERAL NERVES. 477 

there is lordosis present from involvement of the muscles of the back, it 
may be mistaken for Pott's disease, but the deformity is not angular and 
the position assumed will differentiate it. 

Course and Prognosis. — Cases with sudden onset in which the elec- 
trical reaction is rapidly changed and in which atrophy occurs early are not 
favorable for recovery. The average case begins to improve after the first 
month, recovery generally being complete in three months. The sensory 
symptoms clear up first, then the reflexes are obtained. In some cases the 
paralysis may be permanent. Involvement of certain nerves, as the vagus, 
or intercurrent diseases may bring on a fatal issue. 

Treatment. — If the disease is clue to a drug or alcohol poisoning this 
must be stopped at once and eliminatives given. An initial dose of calomel 
is always in order. The child should be placed in a comfortable attitude, 
the limbs encased in cotton wool and lying on a down pillow. The pain 
should be controlled by analgesics, such as the bromids, phenacetin, or even 
codein if necessary for one or two doses. Eest and hot applications during 
the onset, and later massage and vibratory treatment as it is given in 
infantile spinal paralysis is effective. If the extremities are kept in a 
proper position while the disease is in progress, deformities are not likely 
to result and orthopedic appliances will not be necessary. 

Diphtheritic Paralysis. — This is a form of multiple neuritis worthy 
of special note. It is the most common cause in early life and affects for 
the most part only one region, that is the palate. We do not meet with 
the condition as frequently since antitoxin has come into general use. It 
is less likely to follow if the diphtheria has been recognized early and the 
child injected with the serum at once. "We have, however, seen a fatal issue 
in cases that were considered extremely benign and in which the prognosis 
was excellent. Children under two years of age are rarely affected. Malig- 
nant laryngeal cases are more susceptible of involvement. It sometimes 
occurs during the active process, but usually it appears in the third or fourth 
week of convalescence. 

Symptomatology. — Inability to swallow well with regurgitation of 
fluids through the nose or a peculiar nasal twang in the voice may first 
attract attention. The eyes may next show the paralysis, and if this is 
more extensive the lower extremities are affected, followed by similar 
changes in the arms and the muscles of the trunk. Examination of the 
throat will easily disclose a paresis of the pharynx and soft palate ; it is 
relaxed, flabby, and does not take part in the acts of speaking or swallowing. 
Closer examination of the eyes shows weakness of the ciliary muscles, the 
pupil reacting sluggishly and causing defective vision. When the external 
ocular muscles are paralyzed, strabismus results. 



478 DISEASES OF CHILDREN". 

Following the laryngeal cases the loss of voice is particularly marked 
and persistent, and if the paralysis occurs during the intubation period 
difficulty may be experienced in keeping the tube in place. Recovery is 
the general rule; fatal cases resulting from the involvement of the vagus, 
or from aspiration pneumonia when the epiglottis is involved. The course 
depends upon the extent of the paralysis and the regional involvement. The 
average case requires two months for recovery. The muscles of the eyes 
and the palate recover much more quickly than the muscles of the extremi- 
ties. Weakness of the back and inability to properly support the head, 
with the loss of the reflexes, may persist for months. 

Treatment. — Rest in bed and close observation should be insisted 
upon when the first symptoms of paralysis appear. The management will 
depend upon the extent of the regional involvement. Certain cases in which 
there is only aphonia or partial paralysis of the palate will require no special 
treatment, but the heart in all cases should be carefully watched and stimu- 
lation given if necessary. Strychnin nitrate has served us the best for this 
purpose. Where deglutition is interfered with gavage may be necessary, 
although careful feeding from the spoon in small quantities can usually be 
successfully practiced. The food should be as nourishing as possible, and 
the appetite and general health are improved by placing the patient as much 
as possible in the open air. 

Facial Paralysis. 

(Bell's Palsy.) 

Paralysis of the seventh nerve is not an infrequent affection in infants 
and children. 

Etiology. — During infancy it may occur as a result of pressure upon 
the nerve with the forceps or in contracted pelves ■ from impaction upon 
the head. Caries of the petrous portion of the temporal bone accompanied 
with inflammatory exudates may cause paralysis by pressure on the nerve. 

In children over three years of age sudden exposure to cold, which 
in all probability induces an infection, is the commonest cause. It may 
also accompany or be produced by traumatism within the skull, basilar 
forms of meningitis, polioencephalitis, and tumors of the brain. We fre- 
quently see this paralysis following the radical mastoid operation in which 
the nerve may be temporarily injured or destroyed. 

Symptomatology. — Inspection of the child's face will show a droop 
at the mouth on the affected side and the natural folds in this region almost 
or quite disappear, while the angle of the mouth is drawn down. The child 
cannot close its eye, and if attempts are made to do so the eye-ball moves 
upward. It can only blow out the cheek on the unaffected side. The pro- 



DISEASES OF THE PERIPHERAL XERYES. 



479 



truded tongue deviates to the unaffected side and food particles may lodge 
between the cheek and gums. Speech may be affected, while attempts at 
whistling or laughing accentuate the paralysis. 

Prognosis. — This is good for those cases due to sudden chilling. 
Pressure palsies at birth may recover in whole or in part. If due to 
destructive disease in the petrous portion of the temporal bone or to intra- 
cranial diseases, the prognosis is bad. Following operative procedures the 




Fig. 138. — Facial Paralysis. 



prognosis depends upon the amount of traumatism the nerve has sustained, 
and many of these cases slowly recover even after complete section. 

Treatment. — In the mild cases recovery will take place without any 
treatment. The galvanic current is used in the severer cases and in those 
which follow operative procedures in conjunction with massage and mild 
vibratory treatments. As the power returns the child may be encouraged 
to exercise the muscles by imitating grimaces or blowing upon musical 
instruments. If a neglected otitis media is the cause, surgical procedures 
are indicated. 



CHAPTEE XXXVI. 



DISEASES OF THE SPINAL CORD. 

Myelitis. 

Myelitis or inflammation of the spinal cord may be divided according 
to the course into an acute, a subacute, and a chronic form. 

Etiology. — It may result from severe injuries or even considered 
mild in character. It may follow the acute infectious fevers and septic 
processes anywhere in the body. 
It may extend or result from a 
meningitic process. It may also 
be caused by new growths in the 
spinal canal. Syphilis and Pott's 
disease, however, are the two 
causes which are most common in 
children. 

Pathology. — The cord on 
section, in the affected areas, 
shows a congestion of its men- 
inges, while the cord itself has 
been changed to a soft pulpy 
mass. The white matter is with 
difficulty distinguished from the 
gray. Minute capillary hemor- 
rhages are found throughout the 
gray matter and the cells in the 
anterior horn show marked de- 
generative changes. The blood- 
vessels of the cord are dilated with 
proliferation of leukocytes, ama- 
lacious bodies, and degenerated 
axis-cylinders. In the subacute 
or chronic forms some evidences 
of sclerosis may be found. 

Symptomatology. — In acute 
myelitis there is a sudden onset with a temperature which may rise to 
104° F. as a result of the infective process. Painful areas may be 
elicited on pressure along the spine or the tenderness may be subjective. 

480 



^ „ -»■»»•> p» 




SL -~ j 


•.. 







Fig. 139. — Lumbar myelitis, showing con- 
tractures and deformities. 



DISEASES OF THE SPIRAL CORD. 



481 



Clinical evidence will soon appear of functional disturbance of the cord 
and will vary with the intensity and localization of the process. The 
myelitis will affect motion and sensation and derange the functions of 
the bladder and rectum. Paraplegia results, and anesthesia will be 
present in the parts of the body supplied by the nerves which originate 
below the involved area. Thus there is loss of such sensory impulses as 
pain, touch, thermal and muscular sense. A hyperesthetic zone, due to the 
irritation of the nerve fibers may be present above the anesthetic area. The 
reflexes are disturbed depending upon the area involved. 




Fig. 140. — Bed-sores in myelitis. 



Cervical lesions cause a paralysis in all four extremities. In the arms 
it will l^e flaccid in type, while in the lower extremities the palsy will be 
spastic in character. The whole body is anesthetic below the neck. In 
the dorsal region which is most commonly affected in children the upper 
extremities are not involved, while the lower become spastic. The patellar 
and plantar reflexes are increased and ankle clonus is present. Lumbar 
lesions produce a flaccid paralysis in the lower extremities which is later 
accompanied by some degree of atrophy. The urine dribbles away and 
the rectum is incontinent. The reflexes are lost and sensation is absent to 
a point above the lesion. Bed-sores, the result of trophic disturbances, 
cvstitis. and infectious of the urinary tract easily occur, and in fact may 
31 



482 DISEASES OE CHILDREN". 

bring the case to a fatal issue. Contractures and deformities may result 
in the extremities unless measures are taken for their prevention. 

Diagnosis. — The etiological factor, the sudden onset, the paralysis of 
a flaccid type above and spastic below, accompanied with anesthesia and 
derangements of the bladder and rectum should make the diagnosis easy. 

Prognosis. — Lesions in the cervical region are the most dangerous to 
life. Myelitis in the dorsal and lumbar region may cause death from 
infective processes arising in the bladder, rectum, or from bed-sores. The 
younger the child, the more unfavorable the prognosis. Syphilitic cases, if 
the diagnosis is made early, give favorable results under specific treatment. 

Treatment.— Acute Stage. — Absolute rest in bed on an air mattress 
is essential. Ice bladders may be placed over the spine while the fever is 
active and for the relief of pain. The bowels are emptied by a brisk 
cathartic, and the bladder relieved by an attendant accustomed to surgical 
cleanliness. In syphilitic cases the mercurials with the iodids are given. 
If there is intolerance to these, the mercury may be given by inunction. 
If a specific infectious process can be demonstrated, such as streptococci, 
and isolated from the patient's own blood, treatment by vaccines may be 
tried. Bed-sores must be guarded against by scrupulous cleanliness, fre- 
quent change of position, and the daily application of alcohol or astringents. 
If they do develop they should be thoroughly cleansed and treated with 
stimulating antiseptics, such as silver nitrate. 

After the subsidence of the acute symptoms, skilled massage may be 
employed in conjunction with warm tonic baths. Arrangements should 
be made so that the child can be taken out of doors on a roller bed or chair 
so that its nutrition may be preserved and its desire for food stimulated. 

Multiple Sclerosis. 

(Disseminated Sclerosis. ) 

The disease may have its inception in, or it may be associated with any of 
the acute infectious diseases. 

Pathology. Throughout the central nervous system patches of sclerosis are 

found. They may be more frequent in one area than in another, invading the 
brain, the pons, the medulla, the lateral and the posterior columns of the spinal 
cord, or even the spinal roots may be affected. Closer examination shows that 
the myelin sheaths of the nerve fibers are destroyed, although the axis-cylinders 
in the sclerotic areas do not suffer. 

Symptomatology.— At first there may be weakness of the upper and lower 
extremities accompanied with some trembling of the hands and the development 
of a spastic gait. This is followed by an intention tremor which is quite char- 
acteristic of this disease, and which is accentuated by voluntary action on the 
part of the patient. It disappears when the extremity is at rest. Later in the 
disease the tremor may be so intense as to prevent the ordinary activities, as 
dressing or eating, etc. A speech defect now appears ; it is slow, deliberate, care- 
ful, with a tremulous character. It is spoken of as scanning speech. Nystagmus 
or oscillation of the eye-ball appears at this time and is especially marked when 



DISEASES OF THE SPINAL CORD. 



483 



lateral movements are attempted. The pupils usually are contracted and reaction, 
of accommodation to light is sluggish. The mental faculties become impaired, 
memory particularly is poor, and sudden emotional changes; occur on the least- 
provocation. The expression of the face becomes dull and stupid. A spastic form 
of paralysis, not very apparent at first, later becomes well-marked, producing a 
spastic gait. As the disease advances the tremor becomes so intense that walking- 
is impossible, and finally the patient 
is bed-ridden. After a long and 
tedious course the disease finally 
ends fatally, the patient dying of 
some intercurrent disease. 

Treatment.— All that can be 
done for this incurable disease is to 
regulate the life of the patient so 
that an unusual amount of rest is 
secured and the muscles kept in good 
condition by baths, massage, vibra- 
tory treatment, and the galvanic 
current. Drugs do not influence the 
disease, and if given at all they 
should be prescribed for symptoms 
as they arise. 

Hereditary Ataxia. 
(Friedreich's Ataxia.) 

This is a disease occurring in 
the members of the same family and 
characterized by an ataxia with a 
slow but progressive course. 

Etiology. — The disease is hered- 
itary in character, passing often 
through several generations. The 
males or the females of a family in- 
herit the disease. The spinal symp- 
toms in some cases predominate, and 
in others the cerebellar are more in 
evidence. The spinal form occurs in 
the ages of four to seven, while the 
cerebellar form is rarely seen before 
the twentieth year. 

Pathology.— The changes found 
are in the posterior roots. There is 
sclerosis of the posterior columns. 
The spinal cord as a whole is smaller 
than normal. In some cases the 
lateral tracts and the columns of 
Clark are atrophic, especially in the 
type known as the cerebellar, in 
which there is a marked diminution 
in the size of the cerebellum and de- 
generation of its nerve tracts. 

Symptomatology. — The gait is 
the first symptom to attract atten- 
tion. The walk is swaying in character, with the legs held apart (sailor fash- 
ion) ; even while sitting and standing the patient cannot control his position 
accurately. Athetoid movements or tremors are present, especially in the ex- 
tremities. Hyperextension of the great toe may be an early symptom, and later 
deformities, as pes equinus, may develop. Romberg's symptom is obtained in the 




Fig. 



141.— Hereditary 
rich's disease). 



ataxia (Fricd- 
( Sachs.) 



484 DISEASES OF CHILDREN. 

spinal cases, but is more strongly marked in the cerebellar type. The patellar 
reflex is variable and inconstant, and cannot be depended upon for much diag- 
nostic aid. The cutaneous reflexes also remain quite normal. Atrophy of muscle 
after a time occurs and produces such deformities as scoliosis and thus destroys 
the normal spinal curves. Nystagmus is a quite constant symptom. The pupils 
are normal, but other ocular disturbances, as ptosis and strabismus, occur. Optic 
atrophy is not rarely found in the later stages. Dysarthria is commonly present. 
Sensation is unimpaired. The sphincters do not suffer. As the disease pro- 
gresses signs of failing intellect are observed ; these may be preceded by dizziness 
or hysterical phenomena. 

Differential Diagnosis. — Tabes dorsalis may be differentiated by the absence 
of lightning pains and sphincteric changes, and again the ataxic gait is rarely 
seen in infantile tabes, while the pupillary changes are frequent. New growths of 
the cerebellum might simulate a beginning ataxia, but the course is more rapid 
and there is headache and vomiting. 

Course and Prognosis. — The disease is extremely slow in its progress. 
Eventually, after years, the patient is bed-ridden after the musculature is in- 
vaded. Death occurs from some intercurrent malady. The prognosis is invariably 
bad. 

Treatment. — A nutritious diet, massage, hydrotherapy, and the best possible 
hygienic surroundings are our only recourse. Medicinal treatment is symptomatic 
only. Iron is necessary for the anemia. 

Primary Myopathy. 

(Muscular Dystrophy; Idiopathic Muscular Atrophy.) 

For the purposes of clearness and to prevent the confusion which must 
arise in the mind of the reader attempting to gain information on this 
topic, we will embrace all the various described types under this one general 
title of the myopathies. 

Clinically, these types have been separated on a basis of age, as the 
juvenile (Erb type) and the infantile type; on an anatomical basis, for 
example, the facio-scapulo-humeral type (Landouzy-Dejernie) ; and still 
another type is based on the distal involvement, i.e., those in which the 
proximal parts of the body remain intact for many years and only the 
distal parts are affected; finally on an objective basis, in which there is 
enlargement or apparent hypertrophy of portions of the body (pseudo- 
hypertrophic muscular paralysis of Duchenne). 

Pathological classification offers no relief at present from the apparent 
confusion, as the study of muscle components and muscle embryology has 
not as yet advanced sufficiently to warrant such a classification. 

Etiology. — Gowers suggests that the myopathies are due to an inherent 
defective vital endurance. Collins says they are an expression of prenatal 
inadequate endowment. Maternal heredity seems to have a distinct place, 
while paternal heredity because of the early impotency of the diseased father 
is to be disregarded. Several members of one family may be attacked. 
The affection usually begins about the sixth to the eleventh years of life, 
although cases have been reported occuring at birth, and as late as the 
thirties. Boys are more frequently seen with the disease than girls. A 



DISEASES OF THE SPINAL CORD. 



485 



history of trauma is often given as a cause by the parents, but may be dis- 
regarded in a disease of this causation. The acute exanthemata, especially 
scarlet fever, may so lower the resistance that the disease is more readily 
ushered in. 

Pathology. — Various anatomical changes have been found, but the 
reports are various and confusing. The nervous system does not seem to 

be involved in so far as modern technic can 
discover in the normal case. Gowers rejects 
the theory that the disease may be a tropho- 
neurosis. The cells in the dorsal ganglia 
have been found shrunken by Brooks and 
others. The muscles themselves show the 
true pathological changes. Atrophy and 
hypertrophy of muscle fibers may be seen in 
the same specimen. Fatty deposits and con- 
nective-tissue increase are likewise found. In 
some cases (the pseudohypertrophic type) 
the adipose tissue is in excess, while in others 
(the so-called sclerotic type) the connective- 
tissue elements predominate. In the latter 
form the muscles become firm and thin and 
later simply degenerate into fibrous bands. 
The lipomatous type is never hard, but soft 
and flabby. 

Symptomatology. — The first symptom 
noticed may be a weakness in walking or 
clumsiness in going up or down stairs ; later 
the child stumbles or falls on slight provoca- 
(JF , tion. These symptoms come on very gradu- 

ally, so that they are often considered negli- 
gible in the dispensary patients, especially as 
they seem to be physically in very good con- 
dition. The calves may seem to the laity to 
be unusually well developed. When the dis- 
ease is more advanced the gait becomes 
waddling, the legs are not lifted much from the ground. If a test is now 
made a very characteristic attitude will be assumed, namely that of 
"climbing up on himself ;" especially if the patient attempts to pick an 
object from the floor. If placed on his back on the floor, the patient is 
obliged slowly to turn face downward, get on his knees with the aid of his 
arms, then raising his knees he forms an arch and now by grasping his 




Fig. 142. — Pseudo-muscular 
hypertrophy : note size of 
calves as compared to up- 
per extremity. 



486 



DISEASES OF CHILDREN. 



knees he works his hands higher and higher up the thighs until he can 
assume the erect posture. In advanced cases even this is impossible and 
the child is finally bed-ridden. The knee and ankle reflex are diminished, 
and in terminal stages entirely absent. 

The posture is also quite characteristic. Lordosis is sometimes seen 
quite early, and at this time it disappears if the child is asked to sit down. 
As the disease advances, the lordosis is more marked, the head and pelvis 
is held well back and no change is observed in the sitting position. The 




Fig. 143. — Position taken by tbe myopathic when rising from the floor. (Collins.) 

face loses its original expression, becoming dull and mask-like. When the 
disease is well advanced even closure of the eye-lids is accomplished with 
difficulty and articulation is imperfect. All these changes are due to 
atrophy of the facial muscles in some degree. The lower extremities, while 
mainly involved, are not alone affected. After several years the shoulder 
group muscles begin to lose their power, the patient is unable to raise his 



DISEASES OF THE SPINAL COED. 487 

arms and flex his elbows, but they still are able to perform the finer move- 
ments of the hand. The supraspinatus muscle Gowers describes as being 
almost the last to become affected. The atrophic muscles allow the shoulder 
blades to recede from the thorax, forming the winged scapulae so often 
observed in the myopathies. 

Electrical Examination. — Reaction of degeneration is not obtained. 
There is, however, lessened excitability to both currents. 

Complications. — Fractures, contractures, and deformities may occur 
in these cases. The fractures are due to the stumbling or awkwardness 
of the patient. Various theories have been advanced by neurologists for 
the contractures, but suffice it to say, that they are of all possible varieties 
that are reducible and subject to relapse. 

Collins and Climenko give the following order in which the muscles 
are involved : 

Dense, Thickened Muscles. — Calves, sartorius, glutei, triceps, deltoids, 
infraspinati. 

Atrophy. — Pectoralis major, trapezius, serratus magnus (anterior 
portion), latissimus dorsi, biceps, quadriceps femoris, abductors. 

Differential Diagnosis. — The characteristic features are the dispro- 
portionately enlarged calves, the peculiar facies, the gait, the lordosis and 
the peculiar attitude assumed when arising from the prone position. 
Atypical cases are often puzzling and must be differentiated from anterior 
poliomyelitis in which there is a regular corresponding distribution of the 
affected muscles to the portion of cord involved, while in dystrophy this is 
not so. In chronic progressive anterior poliomyelitis, there is, besides the 
regular muscle grouping, the reaction of degeneration and the absence of 
pseudohypertrophy. In syringomyelia the early involvement of the finger 
muscles serves as a guide, for in the dystrophies these often remain unaf- 
fected to the last. Progressive muscular atrophy may be confusing, but the 
age. the origin in the digital muscles and the fibrillary twitchings which 
are present will distinguish the disease. 

Treatment. — These cases, unfortunately, are not amenable to cure. 
Much can be done, however, by obtaining complete control of the patient's 
daily life. Directions should be given to supply a liberal nutritious diet. 
Exercises should be carefully carried out, especially valuable being those of 
the resistant form, the physician or a trained assistant should by example 
teach the child the various movements. Electricity will assist the gym- 
nastic movements if the faradic current is used. Massage will keep up to 
some extent the muscle nutrition. The orthopedist must be consulted and 
deformities corrected in their incipienoy. 



CHAPTER XXXVII. 

DISEASES OF THE BRAIN. 

Meningitis. 

Pachymeningitis, an inflammation involving the dura mater, is rare 
in early life. It may occur in connection with injuries of the skull or ear 
disease, and, in acute cases, usually affects only the external portion of the 
dura. A more chronic form is seen in connection with hemorrhages on the 
vertex, when the pia as well as the internal surface of the dura are involved 
in the inflammation. Such hemorrhages are liable to occur in feeble infants 
suffering from some exhausting disease. This low grade of meningitis is 
more apt to be discovered at autopsy than during life. 

Acute leptomeningitis, or inflammation of the pia, has already been 
described in its two most common forms — acute cerebrospinal meningitis 
and tuberculous meningitis. There is, in addition, a form that may be 
different in its causative factors from these two varieties, although there is 
a certain similarity in symptoms. 

Etiology. — Instead of the diplococcus intracellularis or the tubercle 
bacillus acting as a cause, we may have a number of organisms, seen in 
connection with injuries of the skull, ear disease, or various infectious dis- 
eases, producing inflammation of the pia. In these cases it is more dis- 
tinctly a secondary disease. Any traumatism of the skull from falls or 
blows, suppuration after cranial operations, disease of the middle or internal 
ear or mastoids, can afford access to the various forms of streptococci or 
staphylococci that may attack the pia. It may also be affected by the pneu- 
mococcus, the typhoid bacillus, the influenza bacillus and rarely by the 
Klebs-Loeffler bacillus and the gonococcus. A meningitis may thus be 
seen in connection with pneumonia, typhoid fever, influenza, scarlet fever, 
diphtheria, and as a terminal infection in almost any chronic infectious 
disease. 

Symptomatology. — The symptoms of all varieties of meningitis are 
generally alike, although differing somewhat in the course, rapidity and 
sequence of the various manifestations. As a secondary condition the 
symptoms are apt to be masked at first by the course of the original disease. 
The occurrence of projectile vomiting, convulsions, irregular respiration and 
pulse, stupor, or coma, will call for a diagnosis of meningitis during the 
original infection. The symptoms will vary according to the part of the 
brain involved. Where the inflammation involves principally the convexity, 
as may be seen in pneumonia or malignant endocarditis, there may be no 
symptoms besides the stupor to distinguish it from the original infection. 

488 



DISEASES OF THE BRAIN. 189 

Where the inflammation is at the base of the brain, the cranial nerves are 
apt to become involved and there will be various paralyses and some retrac- 
tion of the head. Where the inflammation extends from the middle ear or 
mastoid, meningitis at the beginning will be unilateral and may continue so 
during the course of the disease, and facial paralysis may ensue on the 
affected side in addition to the other symptoms. The meninges over the 
first and second temporal convolutions are apt to be especially involved in 
the ear cases. In all varieties, when the meningitis is well under way there 
will be hyperesthesia of the skin, and there may be local or general convul- 
sions, photophobia, stupor or coma, and irregularities of the pulse and 
respiration. The temperature is irregular and is influenced by the primary 
disease. The duration of secondary meningitis is usually short, from a few 
days to a week, and the prognosis is bad. We have, however, seen a few 
cases recover where the original disease was controlled and the meningitis 
apparently not extensive. 

Diagnosis. — .Lumbar puncture will aid in differentiating the various 
forms of meningitis by a discovery of the causative organism in the fluid 
withdrawn. On the clinical side the secondary nature of the meningitis will 
be shown by its onset during the course of some general infectious disease 
or when there is a recognized lesion in the ear that is probably being treated. 
Acute cerebrospinal meningitis is sudden in its onset, without any previous 
disease, and as the lesion is apt to involve all the surface of the brain as 
well as the cord, the symptoms are general and severe from the first. Tuber- 
culous meningitis is very slow and irregular in its onset, sometimes taking 
as long as several weeks to attain its maximum intensity, and the brunt of 
the lesion is usually at the base of the brain. 

Treatment. — The principal effort must be directed toward a free 
drainage of any localized suppuration in the ear or skull that may be caus- 
ing the infection. We have seen cases of sinus thrombosis inducing menin- 
gitis, both relieved by surgical measures. The general management is the 
same as in other forms of meningitis. The bowels must be freely opened 
and bromids given to relieve pain. An ice-bag may be intermittently ap- 
plied to the head, and, if there is much evidence of intracranial pressure, 
lumbar puncture may be employed. Small doses of iodid of potash may 
also be tried. The nourishment must consist of milk, meat broths, or 
similar easily assimilable foods. 

Acute Encephalitis. 
This is an inflammation of the hrain tissue usually occurring in connection 
with meningitis from an extension inward of the inflammatory process. The 
symptoms are largely the same as those caused by inflammation of the pia. They 
will vary, however, as to whether the convexity or base of the brain is the prin- 
cipal seat of the disease. In the former case there will be convulsions, paralyses. 



490 DISEASES OF CHILDREN. 

and coina, and in the latter cranial nerve paralyses will form the dominant symp- 
toms. Striimpell describes a hemorrhagic encephalitis occurring in connection 
with influenza or other infectious disease. It may then be seen without a coex- 
isting meningitis. There is severe pain in the head, followed by stupor and 
eventually by coma. In other cases there will be great restlessness, alternating 
with drowsiness. There is apt to be rigidity of the neck; in some cases there 
may be loss of power in an arm or leg, and in others hemiplegia may ensue. 
Fever is present and the pulse and respiration are irregular. In mild cases, 
recovery may occur after one or two remissions, but, in the severer types death 
usually takes place in coma after an interval of from one to three weeks. The 
treatment is the same as in meningitis. 

Abscess of the Brain. 

Cerebral abscess, single or multiple, may occur in early life. The white 
matter is more apt to undergo suppuration than the gray matter, and hence 
abscesses form more frequently within than on the surface of the brain. The 
temporosphenoidal lobes, the frontal lobes, and the cerebellum are most frequently 
attacked. 

Etiology. — Boys are more often affected than girls, and the most frequent 
cause is ear disease, especially if there is a secondary involvement of the petrous 
portion of the temporal bone, when the abscess is usually located in the tem- 
porosphenoidal lobes or occasionally in the cerebellum. Injuries of the skull 
due to trauma and sinus thrombosis occurring in connection with such injuries 
or with ear disease may cause abscess. Infective processes within the nose may 
spread to the brain and induce an abscess, and rarely septic emboli from pus 
formations in distant parts of the body may be carried to the brain and produce 
a similar effect. 

Symptomatology. — As the abscesses do not commonly form in the motor area 
of the brain, the objective symptoms are often very obscure. If, however, the 
abscess does form or spread into a motor area we will have localized symptoms, 
the same as seen in the pressure effects from tumors or hemorrhage. The early 
symptoms are much the same as those of meningitis. There is vomiting, pain in 
the head, fever, and occasionally localized or unilateral convulsions. The fever 
is irregular in type and may be accompanied by chills. If these symptoms ensue 
in connection with acute or chronic disease of the ear, traumatism of the cranial 
bones, or more distant foci of suppuration that may give off septic emboli, we 
may suspect cerebral abscess. In case the abscess becomes encapsulated, there 
may be no symptoms at all, in this respect differing from the disturbing effects 
of solid tumors. Optic neuritis is occasionally present. Where the abscess is 
located at the base of the brain, the different cranial nerves may become affected. 
If the speech centers are involved in the abscess, aphasia may be noted. In some 
cases the pus may rupture into the ventricles, thereby producing serious and 
urgent symptoms. 

Diagnosis. — It is often impossible to differentiate abscess from meningitis, 
encephalitis, or tumors of the brain. If, in connection with the symptoms of 
brain disturbance seen in common with the latter conditions, there is a high 
irregular fever with chills, and if ear disease or trauma of the skull exists, we 
may strongly suspect the formation of an abscess. A differential blood count 
and lumbar puncture may aid in establishing the diagnosis. 

Prognosis.— The prognosis is bad, but if the abscess can be located and 
treated surgically, recovery occasionally takes place. 

Treatment.— Any suppurating area involving the ear or bones of the skull 
must be carefuilv watched and thorough drainage maintained. If the symptoms 
point to internal abscess the surgeon must trephine and endeavor to open and 
drain the abscess. The first and second temporal convolutions are most often 
the seat of abscess following ear disease. The deeper-seated abscesses may be 
located by inserting a needle into the part of the brain suspected. 

Brain Tumors, 

Tuberculous tumors predominate, consisting usually of a caseous tumor of the 
cerebellum. Gliomata, sarcomata, and cysts occur usually in the cerebellum and 



DISEASES OF THE BRAIN. 491 

pons. Males are more prone than females. Infants under six months very rarely 
have brain tumors. Tuberculous and sarcomatous growths are secondary to 
growths elsewhere in the body. 

Symptomatology. — The symptoms are produced by pressure, irritation, exu- 
dation, or interference with the blood supply and vary also with the location 
involved. 

Headache. — This is persistent and boring in character, causing restlessness, 
insomnia, rolling of the head, cephalic cry, and photophobia. Occasionally the 
pain is well localized at the site of the tumor. 

Nausea and Vomiting. — This is persistent and without causal relation to 
food. It is projectile in character. 

Vertigo or dizziness are common symptoms, elicited by change of position. 
The gait may be reeling. 

Ocular symptoms are particularly helpful — optic neuritis in one or both 
eyes is usually present, and especially so when the cerebellum is affected. Optic 
atrophy may follow and is seen early if the chiasm is involved. 

Convulsions occur when the cortex and motor areas are involved. They are 
general or local in character. Tumors which have not as yet invaded the cortex 
produce paralysis and later convulsions. 

Localization. — Special symptoms will be caused by involvement of areas 
with known functions, and are not different from those manifested in adults. 
They will not be enumerated here. 

Diagnosis. — From abscess of the brain, tumors may sometimes be distin- 
guished by the absence of local causes, lack of temperature, and the slower 
course. Septic symptoms, if present, are indicative of abscess, and are confirmed 
by blood examination. Macewen's sign may be of help if other confirmatory signs 
are obtained. 

Tuberculous tumors occur generally in the cerebellum, and there may be 
evidences of tuberculous infection elsewhere in the body. Lumbar puncture 
should always be performed if any doubt remains, as a cell count and chemical 
analysis may give considerable assistance. 

Treatment. — Operative procedures are carried out with great risk in early 
life even when the conditions for removal of the growth are favorable, but often 
this is the only hope for relief or cure. The operation of decompression can at 
least be done to relieve intracranial pressure. Medical treatment should be 
directed to the relief of urgent symptoms and in the syphilitic cases specific 
medication should not be delayed. 

Infantile Cerebral Palsies. 

(Spastic Diplegia; Paraplegia or Hemiplegia.) 
A paralysis of various parts of the body may occur, due to congenital 
defects, birth injuries, or hemorrhages in the brain in later infancy or early 
childhood. 

Etiology and Pathology. — We may divide the causes into those 
operating before birth, during birth, and some time after birth. During 
intrauterine life the growth of the brain may be arrested by hemorrhage, 
by lack of cortical development, or by cysts. A condition known as poren- 
cephaly may sometimes be present. The exact cause of these accidents or 
defects is difficult to ascertain or explain. They have been referred to acci- 
dents during pregnancy, such as falls or blows on the abdomen, to uremic 
convulsions, to severe illness in such forms as pneumonia and typhoid fever, 
and to sudden shocks in women with a neurotic hereditary tendency. The 
causes operating during birth are due to prolonged pressure on the fetal 



492 DISEASES OF CHILDREN. 

head in tedious labors or to the unskillful use of the forceps, as already 
noted in the chapter on Birth Injuries. The hemorrhage is nearly always 
on the cortex, and may be followed by meningoencephalitis, sclerosis, the 
formation of cysts, or by atrophy of the underlying tissue. In later months 
or years, cerebral palsy may follow a severe convulsion or a prolonged 
paroxysm of whooping-cough, and occasionally certain infectious diseases, 
such as scarlet fever, small-pox, measles, and typhoid fever, may be respon- 
sible for the condition. Direct injury to the skull may also act as a cause. 
The rupture of cerebral vessels usually takes place on or near the cortex 
instead of in the lenticular nucleus, as in adults. This has been explained 
by the delicate, fragile structure of the small blood-vessels on the surface of 
the brain. Thrombosis and embolism may act as a cause of cerebral palsy 
in children, but not so frequently as in later years. Rheumatism, valvular 
disease, or pneumonia favor embolism, while any exhausting condition may 
lead to thrombosis. 

Various changes occasionally take place in the brain following a hemor- 
rhage. Chronic meningitis, sclerosis, softening, or atrophy, with various 
degrees of secondary degeneration and cysts, may be mentioned in this con- 
nection. The following tabular classification of infantile palsies is taken 
from Sachs and gives an admirable compendium of the subject : 

Groups Morbid Lesions. 

[ Large cerebral defects (porencephaly). 
., _ . , . . I Defective development of pyramidal tracts. 

1. Paralyses of intrauterine onset. .. j A g en esis corticalis (highest nerve elements 

[ involved). 

[Meningeal hemorrhage, rarely intracerebral 
9 T4 . ,. ' . J hemorrhage. Later conditions : Meningo- 

z. .Birtn palsies <j encephalitis chronica, sclerosis, and cysts ; 

partial atrophies. 

Hemorrhage (meningeal, and rarely intra- 
cerebral) ; thrombosis (from syphilitic 
endarteritis and in marantic conditions) ; 
embolism. Later conditions : Atrophy, 
cysts, and sclerosis (diffuse and lobar). 

j Meningitis chronica. 

j Hydrocephalus (seldom the sole cause). 

I Primary encephalitis ; polioencephalitis 

[ acute (Striimpell). 

Symptomatology. — The form and character of the paralysis depend 
on the extent and situation of the lesion. A double brain lesion is apt to 
occur early, either before or during birth. Diplegia or paraplegia may thus 
result. Hemiplegia is occasionally seen, although not so often, in this early 
paralysis, and monoplegia is rarely, if ever, encountered at this time. The 
loss of power is not apt to be complete, and the affected muscles are usually 
in a spastic condition. Very rarely the muscles may be flaccid. Contrac- 



3. Acute palsies (acquired) 



DISEASES OF THE BKA1N. 



493 



lures take place early and give rise to various deformities. The groups of 
muscles most markedly affected by these contractures are the flexors of the 
legs and feet and the flexors and pronators of the arms. There is usually 
a marked exaggeration of the tendon reflexes. Later on there may be 
athetoid and occasionally choreiform movements in the palsied muscles. 
Sooner or later other evidences of cerebral defect, besides the paralysis, are 
apt to manifest themselves. Epilepsy is perhaps the most common of these 
disturbances. Many cases of epilepsy that are seen in later life have had 
their origin in some hemorrhage or defect that originally produced a palsy 
in which recovery may have largely taken place. Another unfortunate 
sequel in these cases is idiocy of a mild or severe grade. The latter type is 

more apt to follow the widespread 
palsies produced by double brain 
lesions, and shown by diplegia or 
paraplegia. 

In cerebral palsy occurring af- 
ter birth, the onset is usually sudden 
and the form hemiplegic. It is rare 
to have both sides of the brain in- 
volved, as so often occurs before or 
during birth. In hemorrhage on the 
cortex, there is excitation as well as 
loss of function, and hence convul- 
sions are usually present at the be- 
ginning. In later life, when the 
hemorrhage is usually in the lenticu- 
lar nucleus, there is loss of function, 
but little or no excitation, ilphasia 
will be noted in older children if the 
speech centers are involved. The 
paralysis is usually not complete and 
may be followed by contractures and 
athetoid movements. 7\ nile there is 
not the marked and rapid atrophy 
seen in spinal affections, there is usu- 
ally a failure of proper development 
m the palsied muscles. There is likewise no reaction of regeneration as in 
spinal paralysis. Considerable recovery of function often takes place, and 
in some cases the principal disturbance will finally be shown by athetoid or 
choreic movements rather than by paralvsis. Fortunately, mental impair- 
ment and epilepsy rlo not so frequently follow as in the birth palsies. We 




Fig. 144. — Spastic paraplegia : 
crossecMeg progression. 



494 DISEASES OF CHILDREN. 

may say, in general, that these acute cerebral palsies occur only in early 
childhood, usually under five years. 

Diagnosis. — We may try and distinguish the prenatal and birth pal- 
sies from those occurring later by the history of the case and the extent of 
the paralysis, the diplegias and paraplegias being nearly always of the early 
class. The cerebral is distinguished from spinal palsy by its incomplete 
form, the absence of rapid atrophy, by the spastic muscles, contractures or 
athetosis, exaggerated reflexes, and normal electrical reactions. 

Treatment. — The greatest efforts must be directed toward prevention. 
The expectant mother must lead a quiet, healthy life during pregnancy, 
avoiding undue excitement and exposures that may lead to accident. The 
labor must not be unduly prolonged nor the fetal head allowed to undergo 
pressure for too great a time in the maternal passages. The forceps may 
be required to prevent this, but they must be applied with care, as extreme 
pressure from this source may likewise provoke a hemorrhage. Glandular 
extracts as pituitrin, and the narcotic drugs (twilight sleep) should be given 
cautiously to prevent injurious action on the unborn. After labor, if there 
is any evidence of cerebral injury, extra care must be taken to keep the 
infant very quiet. If it cannot suckle, the mother's milk may be carefully 
given by a medicine dropper. Where there are twitchings or convulsions, 
small doses of bromid of sodium (2 to 3 grains) may be given every few 
hours. A lumbar puncture may give direct evidence of the hemorrhage, in 
which case operative relief should be considered. In the later cases of cere- 
bral apoplexy, cold may be applied to the head, and a free movement of the 
bowels induced. Small doses of the bromid of sodium may likewise be given, 
and later on this may be combined with the iodid of potash. Massage and 
electricity may be used in trying to overcome contractures, but in old cases 
orthopedic appliances are usually required to overcome the various deform- 
ities. The services of the surgeon in cutting tendons and thus relieving 
tension and deformity are likewise often required. 

Hydrocephalus. 

Hydrocephalus is an enlargement of the skull, due to fluid within the 
ventricles or in the subdural spaces. 

Several classifications have been made of this condition. We are 
inclined to accept the etiological as offering the greatest help to the student. 

H ~ ., , , , , , (Internal — usual, ventricular. 

1. Congenital hydrocephalus {External — rare, subdural. 

f Acute — inflammatory diseases of the men- 
inges. 

2. Acquired hydrocephalus \ Chronic — result of inflammation of the 

external or internal coverings of 
[ the brain. 



DISEASES OF THE BRAIX. 



405 



Congenital External Hydrocephalus. — 'Very few cases of congenital 
external hydrocephalus have been reported. The condition seems to result 
from an intrauterine meningitis or from congenital maldevelopment of the 
brain. 

Congenital Internal Hydrocephalus. — As a result of intrauterine 
disease, there is an abnormal exudation of fluid which either, appearing 
early, arrests the devolpment of the brain, or, appearing later, causes its 
atrophy. 

Etiology. — Parental alco- 
holism, tuberculosis, syphilis, 
and neurotic diseases have a 
distinct influence in its causa- 
tion. 

Symptomatology. — The 
fluid within the cranium, which 
may be as much as 5,000 c.c, 
does not allow normal ossifica- 
tion to take place; hence the 
tremendous enlargement of the 
vault; the sutures are widely 
separated, and the enormously 
large fontanels may bulge. 
The bones themselves are thin 
plates covered with a tense 
skin, and the superficial veins 
are prominent. The overhang- 
ing forehead and the pressure 
within causes dislocation of the 
eyes, so that only small por- 
tions of the pupils are seen; 
the face appears abnormally 
small and is usually emaciated. 
The expression is dull and star- 
ing, strabismus, nystagmus, 
lack of accommodation of the pupils and even atrophy of the optic nerve 
may be present. The child is pale, wasted, has a purposeless cry, and does 
not, as a rule, thrive even on a well-regulated diet. 

The extremities may be held in a characteristic position, that is, the 
arms are flexed and the hands clinched. The infants do not show any 
interest in their surroundings, may not recognize their parents, nor care for 
toys. Convulsions may occur from time to time. In older children pres- 




Fig. 145. — Hydrocephalic Infant. 



496 DISEASES OF CHILDREN. 

sure over the motor areas, due to the fluid, produces spasticity, rigidity or 
paralysis. Walking is delayed because of improper musculature, lack of 
intelligence and a tendency to the spastic gait. The patellar reflexes are 
increased. Children who have a considerable amount of fluid are unable 
to support the head, on account of muscular weakness and the weight. A 
peculiar so-called hydrocephalic cry is occasionally heard in these cases. 
In some cases the enlargement of the head may increase gradually or sud- 
denly with cerebral symptoms after a period of quiescence. 

Diagnosis. — In well-marked cases it is simple. The relation of the 
circumference of the head to the chest and the delayed mentality should 
arouse suspicion. The fluid contains a trace of albumin and sugar. The 




Fig. 146. — Congenital internal hydrocephalus. 

large head in rickets is square, and other evidences of the disease are found 
in the osseous system. 

Prognosis. — This is directly dependent upon the amount and increase 
of cranial enlargement as indicated by measurements. As a rule, these 
children, especially the congenital types, succumb to intercurrent diseases, 
dying soon after birth or in early childhood. Those cases in which the intel- 
lect is not greatly altered may be fairly bright, but their deformity and 
peculiar gait necessitates special school facilities. A certain number live to 
be bright and useful members of society. 

Treatment. — Medicinal treatment is of little avail. Those with a 
syphilitic history should be given the benefit of the mercury and iodids. 
Surgical treatment of all sorts has been advised and soon abandoned, be- 
cause of the poor results obtained. Pressure bandages, puncture of the 



DISEASES OF THE BRAIN. 



497 



ventricle, injections and insufflations into the ventricles, permanent drain- 
age from the ventricles into the subdural space, are among the various 
means which have been tried at the Post-Graduate Hospital, and each has 
been disappointing. Lumbar puncture, or aspiration of the ventricles for 
the relief of pressure symptoms, is the only procedure which sometimes 
gives good results, and in some instances these repeated punctures have 
effected a cure in selected cases. 

Microcephalus. 

By microcephalus we understand 
that condition in which there is ar- 
rested or defective development of 
the brain with a correspondingly 
small cranial cavity. 

Microcephalus probably origin- 
ates during fetal life or soon after- 
birth. The fontanels are closed and 
premature ossification of all the su- 
tures takes place. The vertex is, as 
a rule, dome-shaped, although it 
may be asymmetrical with a sharply 
receding forehead. AYhen the condi- 
tion begins later in infancy, it is con- 
sidered to be the result of minute 
hemorrhages into the cortex arising 
from a meningeal disease or an 
eclamptic seizure. 

The diagnosis of this form of 
idiocy is made upon the abnormality 
of the head. The measurements are 
taken of the head, chest, and length 
of the infant, and the relations com- 
pared to those of the normal infant of corresponding age (see chapter on 
Development). The symptoms do not differ from those of idiocy or imbecil- 
ity, as described on page 498. The operative treatment of craniotomy which 
was formerly advanced for these cases we have entirely abandoned as giving 
no results. 




Fig. 147. 



Microcephalus. 
hare-lip. 



with double 



Idiocy, Imbecility, Feeble-mindedness. 

Idiocy may be divided into three groups: the prenatal, the acquired, 
and the myxedematous. In each of these the undeveloped intellect has 
32 



498 



DISEASES OF CHILDREN. 



been more or less permanently impaired. Minor degress of idiocy are desig- 
nated as imbecility or f eeble-mindedness ; the mental impairment being 
dependent upon the extent of the cerebral lesion. 

Etiology.— The children of insane parents or of those who have been 
the victims of alcoholism, epilepsy, hysteria, chorea, or syphilis, may be born 
idiotic. Consanguineous marriages, especially among those who have suf- 





Fig. 148. 



Imbecile with marked 
strabismus. 



Fig. 149. — Idiocy, with blindness. 



fered from some neurotic disease, may produce idiotic children. The ac- 
quired types are generally the result of injuries received at the time of birth 
and from convulsions, both of which result in the rupture of delicate blood- 
vessels, with later sclerotic changes. This latter change may also take place 
after attacks of inflammation of the brain or its meninges. The relation of 
idiocy to hydrocephalus and epilepsy has been considered elsewhere. 



DISEASES OF THE BRAIN. 



•±99 



Symptomatology. — From the physical standpoint an idiot may re- 
semble a normal child. He radically differs, however, in his powers of 
cerebration. He is unable to acquire any conceptions and he has no sense of 
fear. As a rule, the diagnosis can be made by observation alone. The 
expression is vacant and the eyes are continually roving from place to place. 

In younger children saliva dribbles over the 
chin. The teeth may be irregularly erupted 
and usually are sharp and carious. Other 
stigmata of degeneration may be seen. The 
child cannot distinguish its parents, it has 
no acquired speech, but makes unintelligible 
animal sounds, it becomes irritated or laughs 
without provocation, and when awake keeps 
in constant motion. 

There are no habits of cleanliness. Food 
is eaten ravenously and not selected with any 
relation to taste or desire. Imbeciles and fee- 
ble-minded children differ from idiots in that 
they may be able to recognize their parents 
and appreciate some simple objects, as toys. 
A few words may be learned and habits 
of personal cleanliness may after a time be 
acquired. 

Prognosis. — The prognosis for the idi- 
otic child is invariably bad. The feeble- 
minded are capable of some degree of devel- 
opment when placed under special tuition. 

Treatment. — The parents of idiots 
should be advised that an institution is the 
proper place for their afflicted child, especially 
if there are other children in the family. 
Here he will be unmolested and allowed 
more freedom than is possible when in his 
home. 

Feeble-minded children, if the circumstances permit, may be placed in 
institutions arranged for the care and training of mental defectives, where 
under almost private tutelage they may be trained along the lines in which 
they show any aptitude. In some of our States such institutions have been 
provided for these unfortunates, so that even the children of the poor may 
receive this beneficial training. 




Fig. 150. — Mongolian idiocy 
G yr. old child. 



500 DISEASES OF CHILDREN. 

Mongolian Idiocy. 

This form of idiocy, because of several simulating features, is often 
mistaken for cretinism. The resemblance to cretinism is seen in their 
stunted development, in the large and often protruded tongue, the thickened 
lips, and open mouth. A Mongolian idiot, however, may, even in infancy, 




Fig. 151. — Mongolian idiocy in infancy. 

be distinguished by the peculiar expression of the face, which, when anal- 
yzed, is seen to result from slanting eyelids like those seen in the Mongolian 
race. Although the eyes converge, they are relatively further apart than 
in the normal, the nose is small and flat, and the contour of the head is 
distinctly rounded. The skin in the early months is not harsh and dry; 
it may be soft and velvety. A rather characteristic feature is seen in the 
flabby muscles and mobility of the joints, which allow the thighs, for 
example, to be flexed with extraordinary ease upon the body. The head is 
not held erect until the age is well advanced, the fontanels remain open late, 
and the nutrition is impoverished in spite of good feeding. The bones of 
the hands and wrists show deviations from the normal, which are best seen 
in a radiograph, although the incurvation of the little finger and the short 
second phalanx is often easily discernible. 

The mongoloid idiots further differ from the cretins in that they are 
not influenced by thyroid therapy, and if they pass through the period of 
infancy they may show some degree of intelligence. Their memory is good 



DISEASES OF THE BRAIN. 501 

and many have a liking for music. Special pedagogic procedures are there- 
fore indicated to prompt further development. Before receiving any in- 
struction the vision should be corrected, as almost invariably the eyes are 
found to be defective. 




Fig. 152.— Idiocy. 

Amaurotic Family Idiocy. 

This is a disease occurring in Hebrew families and dependent upon arrested 
cerebral development and characterized by blindness and changes in the region 
of the macula lutea. 

Tay. an oculist, first described the ocular symptoms, while Sachs, in this 
country, further elaborated the clinical and pathological picture. 

Etiology. — The causes of this disease are still undetermined. More than 
one case may occur in the same family, and nearly all the cases thus far observed 
have been among Hebrews. 

Symptomatology. — The first symptoms appear about the sixth month. Up 
to this time the child may have been considered healthy and robust. The first 
symptoms noted are that the child makes no effort to hold up its head, moves its 
limbs only slightly, and takes no interest in those about him. If some degree of 
nystagmus is present the fact that the child is blind escapes the attention of the 
parents or even of the physician. If seated the head falls back and the lower 
extremities give evidences of complete paralysis. Later in the disease spasticity 



502 DISEASES OF CHILDREN". 

occurs in these extremities with increase of the reflexes. As the disease advances 
the weakness becomes intensified, and usually after the first year there is total 
blindness and evidences appear of mental deficiency. Strabismus is occasionally 
observed and is usually associated with the nystagmus. Convulsions are rare. 
The hearing may be abnormally acute, the infant being startled from its apathy, 
for example, by clapping the hands. Ophthalmoscopic examination fixes the 
diagnosis when Tay-Kingdon's cherry-red spots on a white background is found 
in the region of the macula lutea. Subsequently, optic nerve atrophy results. 
Before the fatal ending emaciation and other subjective and objective symptoms 
of marasmus appear. The prognosis is invariably bad, the children rarely living 
beyond the second year. 

Treatment. — Beyond giving the prognosis as to the duration of life, we are 
powerless to give aid in this disease. 

Modified Binet-Simon Tests for Mental Deficiency. 
These tests, while not ideal, make a very satisfactory approximation of the 
mental age of the child. The examiner should put the child at ease and be 
certain that the English language is understood. 

MENTAL TESTS. 
Arranged for the early months of life when the determination of minor degrees of 
deficiency is more difficult. 

Six Months. 

1. Child sits alone. Should sit unsupported for 2-3 minutes. Will sit up indefinitely 
with some support at back. 

2. Child balances head. 

3. Turns head in direction of unexpected sound. 

4. Eye will follow a bright object, such as a red ball or other attractive object. 

5. Child will seize an object and hold it. Thumb coordination should be noticed at 

this age. 

Nine Months. 

1. Child sits unsupported indefinitely. 

2 Child plays with toes and hands. Will grasp for attractive objects. 

3. Child can draw itself into sitting position with slight assistance and attempt to 

4. See if child can transfer object from one hand to another. 

5. Child holds cup or nursing bottle. 

One Year. 
1. Sits and stands unsupported. . 

2 Use of pencil. Marks back and forth on paper with pencil. Place the pencil in 
child's hand and he will imitate the movement though effort is crude. 

3. Child will imitate a few sounds though does not talk at this age. Try such 
sounds as mamm-mam — da-da — or have mother do so 

4. Child will imitate play with toys. Use a bell, a rattle, or place a ball in a box, etc. 

5. Child begins to show a preference for toys. 

Eighteen Months. 

1. Stands and walks unsupported. Runs _ . ■ 

2. Begins to recognize common objects and animals in pictures. Will point to them 
when directed, but does not enumerate. " . - . - 

3 Recognizes " baby " in mirror in a few seconds. Place the mirror in front of 
the babv and hold it there. Child recognizes it is " baby " _ _ 

4 Child says a few words such as mama, papa. baby. Will imitate a few simple 
movements such' as clapping hands, or placing hands on head or ears. > 

5. Child will unwrap a piece of candy. Let the child see you wrap the candy in 
paper and he will unwrap it. 

Two Years. 

1 Child will point out simple objects in a picture and name them. 

2. Use of pencil. Child will mark back and forth on paper imitating the examiner. 
Will also use rotary movement. . .. „ (1 „. .. . ,, . 

3. Obeys simple commands. Such as " Throw me the ball," Give the ball to 
mama." " Give me the pencil." and similar ones. 

4. Imitation of simple movements. Hold arms up high, palms on head, put ball on 
head. etc. Should imitate three out of five. 

5. Knows features. Will find them on doll or mamma when unwilling to do so on 

self 

Two and One-Half Years. 

1. Will talk in short sentences. 

2. Imitation better than at two. 

3. Copy a circle. Effort fairly good. 



DISEASES OF THE BRAIN. 503 

4. Recognizes self in mirror in 2-3 seconds. Place the mirror in front of child and 
remove nuickly. Child will name the picture for self at this age instead of calling it baby. 

5. Repeat two numerals. Show picture containing group of two or any other group of 
two, and child will repeat the two numerals after the examiner. 

Three Years. 

1. Enumerate objects in a complex picture and can tell something about it. Shows 
some imagination. 

2. Repeat sentences containing six syllables. 

3. Repeat two or three numerals. 24. 246. 

4. Knows family name. 

5. Will untie bow-knot and investigate parcel when the object has been tied before 
the child. 

IDIOTS. 

Mental Age 1 and 2 Years. 

1. Move lighted match slowing before child's eyes. 

(Full credit given if eyes follow light for briefest period.) 

2. Place a wooden block in child's hand. 
(Credit given if block is grasped.) 

3. Show the wooden block without touching child with it and say, " This is for 
you, don't you want to play with it?'' 

(Credit given if child takes it.) 

4. Offer child a piece of wood and a piece of chocolate the same size. 

(Credit given if he eats the chocolate and does not attempt to eat the wood.) 

5. Show child a piece of chocolate, then wrap it in paper and present it to him, 
telling him to eat it. 

(Credit given if he removes the paper before eating.) 

6. Make simple movements, clapping the hands, sitting down, standing up, etc., and 
tell the child to do the same. 

(Credit given if one intention is accomplished. 

IMBECILES. 

Mental Age 3 Years. 

7. Show me your nose. Show me your eyes. Show me your mouth. 

8. Listen well and repeat what I say. 4 ; 3-7 ; 6-4 ; 5-8. Pronounce numbers slowly 
and distinctly with one-half second interval between, one pair at a time. 

(Full credit given for one exact repetition.) 

9. Place picture before child and ask, "What is that?" or "What do you see 
there?" 

(Full credit given if some objects are enumerated.) 

10. "What is your name?" If first name is given — "And your other name?" 
(Surname required.) 

11. Listen well and repeat what I say : " I am cold and hungry." 
(No errors of any kind allowed.) 

Mental Age 4 Years. 

12. "Are you a little boy or a little girl?" If necessary — "Are you a little girl?" 
"Are you a little boy?" 

13. Show child a penknife, saying, "What is that?" "What is it called?" Then 
show penny, and finally key, asking same questions. 

13. (Names of three objects required. 

14. " Listen well and repeat what I say : 4-9-2 ; 3-7-4 ; 5-8-1." 
(Full credit given for one exact repetition.) 

15. " You see these two lines. Tell me which is the longer." 

Mental Age 5 Years. 

16. Place two boxes, weighing 3 and 12 grams respectively, on the table before the 
child, leaving a space of 5 or 6 centimeters between them and say. " You see these two 
boxes? T<']] me which is the heavier?" Repeat, using boxes weighing 6 and 15 grams, 
and repeat again, using first pair. 

(If there is still doubt about the child's ability to compare weights, repeat process.) 

17. Draw a square. 3 to 4 centimeters in diameter, with ink and ask the child to copy 
it, giving him pen and ink to do so. 

18. " Listen well and repeat what I say : My name is Charley. O ! the naughty dog." 

19. Place four pennies in a row before the child, and say: "Do you see these 
pennies? Count them and tell me how many there are." 

(Child is required to point to each with finger, no error allowed.) 

20. Place an oblong card on the table before the child, and place also, nearer to the 
child, two triangular cards formed by cutting another card like the first one. in two. 
along a diagonal. Place these two triangular cards in such position that their hypothenuses 



504 DISEASES OF CHILDREN. 

form a right angle, one with the other, and say to the child : " Put these two pieces to- 
gether so that they will form one card like this " (indicating the oblong card) If the child 
turns over one triangular piece without noticing it, it is permissible to begin again. 

Mental Age 6 Years. 

21. "Is it morning now?" "Is it afternoon?" 

22. "What is a fork?" "What is a table?" "What is a chair?" " W>at is a 
horse?" What is a Mamma?" 

(If some use of three of the objects is mentioned, the response is considered 
correct.) 

23. Draw a diamond figure with ink and ask the child to copy it, giving him pen and 
ink for the purpose. 

24. Place 13 pennies in a row on the table before the child, and say : " Count these 
pennies for me, pointing to each one as you count it." 

25. Show pictures of faces. "Which is the prettier of these two faces?" 
(No error allowed.) 

Mental Age 7 Years. 

26. " Show me your right hand." " Show me your left ear." 
(No error allowed.) 

27. Show pictures as in Test 9, requiring descriptions. 

28. " Take this key and put it on that chair, bring me that book lying on the table. 
and open the door." 

(Repeat these directions distinctly twice.) 

29. Place three two-cent and three one-cent stamps on the table before the child. 
Be sure that he knows the 2's from the l's, and then ask him to count how 
much they would all cost. 

30. Have 4 pieces of colored paper, red, blue, yellow and green. Point to each, 
asking, " What is this color? " 

(No error allowed.) 

MORONS. 

Mental Age 8 Years. 

31. (a) " Do you know what paper is? " " Do you know what cardboard is?" "Are 
they alike?" "In what way are they not alike?" 

(b) "Have you ever seen a fly?" "Have you ever seen a butterfly?" "Are 
they alike? " " In what way are they not alike? " 

(c) "Do you know wood when you see it?" "Do you know glass when you see 
it?" "Are they alike?" "In what way are they not alike?" 

(Two satisfactory answers required). 

32. " I want you to count backward from 20 to 0. Like this — 20-19-18." 
(This must be accomplished in 20 seconds ; one error allowed. 

33. Four pictures are shown, one at a time, and the question asked with each, " What 
is missing in this picture?" 

(Three correct replies required.) 

34. " What is to-day? " " What date is it? " 

35. " Listen well and repeat what I say : 3-8-5-7-1 ; 9-2-7-3-6 ; and 5-1-8-3-9." 
(One group given at a time. One exact response required.) 

Mental Age 9 Years. 

36. In a pile before the child place the following coins : Ten pennies, two nickels, two 
dimes, one quarter, one half dollar. Then propose a game of storekeeping, the child to keep 
the store and use the pile of money to make change, the experimenter to be the customer. 
Add some articles for sale. Then buy something for four cents. Give the child a quarter 
and require the change. 

37. Test No. 22. Definitions superior to use are required. 

38. Show the child successively a penny, a dime, a dollar, a quarter, a nickel, a half 
dollar, a two dollar bill, a ten dollar bill, a five dollar bill. Ask " What is this? " 
with each. 

39. Name the months of the year in order. 
(One error allowed. Time 15 seconds.) 

40. (a) "If you were going away and missed your train what would you do?" 

(b) "If one of the boys should hit you without meaning to, what would you do 
about it?" 
(c) " If you broke something belonging to some one else, what would you do about 
it?" 
(Two good responses required.) 



SECTION XIV. 

CONGENITAL MALFORMATIONS AND 
DEFORMITIES. 



CHAPTER XXXVIII. 

CONGENITAL MALFORMATIONS AND DEFORMITIES. 

A careful examination should always be made of the newly-born child. 
Any deviation from the normal condition may be due to prenatal malforma- 
tions, foetal inflammations, or to injuries received during the process of 
birth. 

Tongue-Tie. 

A short frenum causes this deformity. The tip of the tongue is 
depressed and fixed in the floor of the mouth so that often it cannot be 
normally protruded. Sucking and articulation are difficult, and when 
allowed to persist there is often a lisp in the speech. 

The treatment is surgical, and consists in dividing the frenum with 
blunt scissors and stripping back the divided tissue. Parents often incor- 
rectly attribute backwardness in talking to a possible tongue-tie. Mental 
defects or deafness may instead be found as the real cause if the child is 
much beyond the age when it should be talking. 

Harelip. 

When the central process fails to fuse with the lateral processes which 
go to make up the upper half of the face in fetal life, a condition known as 
harelip results. This may be unilateral or bilateral, the fissure varying in 
extent from a slight cleft to a fissure extending through the entire length 
of the lip into the nasal fossa. A cleft palate may also be present. 

The treatment is surgical, and should be undertaken as soon as possible 
after the child is well started in its feeding — three months of age being the 
time selected by the majority of surgeons. Nursing is sometimes impos- 
sible, but the maternal milk should be pumped out and fed by the dropper 
or the Breck feeder (see Fig. 2). A nipple shield can sometimes be used 
to advantage, or the milk can be fed from a nursing bottle when the babe 
cannot suckle the mother's breast. Nursing should not be discontinued 
except for exceptionally good reasons. 

505 



506 DISEASES OF CHILDREN. 

Cleft Palate. 

In this condition a fissure is seen in the roof of the mouth, involving 
the soft palate, the hard palate, or both. 

It occurs when the palatal arches in fetal life fail to fuse. Cleft palate 
often occurs with harelip, particularly when the latter condition is double. 

Owing to the gap in the mouth the infant usually cannot nurse nor 
feed from a bottle, and it is often necessary to resort to feeding with a 
dropper or by gavage. Nipples with a flexible wing have been devised to 
accommodate these cases for bottle feeding, the flap being so arranged that 
it fits snugly to the upper lip and covering the cleft. 

Such deformities as cleft palate and harelip make feeding very difficult, 
and these cases frequently die of inanition, unless carefully handled. 

The treatment is surgical ; the operation should be performed as early 
as possible. The surgeon who is to operate must decide upon the preferred 
age, which depends upon the character of the operation and the nutrition of 
the child. Some surgeons operate at the end of the second year, while 
others prefer to wait until the arches are well developed. 

Congenital Branchial Cysts. 

Certain tumors of the neck in infants and young children have their origin 
in an incomplete closure of one of the branchial clefts. Early in the fetal life 
of the vertebrata there appears under the projecting frontal process a series of 
four plates, bounding the cavity of the pharynx on the side. These plates unite 
to form four parallel arches separated, by transverse clefts. The branchial clefts 
unite, and by a process of morphological change form various structures of the 
neck. If this regular process of development is interfered with from any cause, 
various abnormalities may result, as a condition intended to be merely tem- 
porary remains more or less permanent. Hence, according to the various grades 
of arrested development, we may have marked deformities, branchial cysts, or 
the remains of fetal epithelial tissue destined to proliferate at a later day and 
form a cyst. There likewise may result fistulous tracts from non-union of the 
branchial clefts, particularly from the lowest one. These have been divided 
into: (a) complete branchial fistula?, open the whole length of the tract; (b) 
fistula? having only an external orifice and ending in a cul-de-sac, which is the 
commonest form; (c) fistula? with only an internal orifice. More frequently the 
branchial tract is closed at both the pharyngeal and cutaneous ends, and a cyst is 
formed between. 

Senn has made the following classification according to the cystic contents : 
1. Mucous branchial cysts, due to imperfect closure of the upper portion of the 
branchial tract with retention of its physiological secretion. 2. Atheromatous 
branchial cysts, usually located in the second and third branchial tracts in the 
region of the hyoid bone. 3. Serous branchial cysts, having a thin-walled capsule 
lined with pavement epithelium, and following the defective obliteration of any of 
the branchial clefts. 4. Hemato-cysts of branchial clefts, in which the serous fluid 
of the cyst has been discolored by hemorrhages into the sac. 

The contents of these cysts are always such as may be produced by some 
kind of epithelium, and in this they differ from true dermoid cysts that may 
contain the secretion of the various glands and appendages of the skin. 

Treatment. — The object of treatment in these cases is, of course, to radically 
destroy the membrane that secretes the serous contents of the tumor. In struc- 
ture, the cyst consists of a thin capsule of connective tissue, lined on its inner 



CONGENITAL MALFORMATIONS AND DEFORMITIES. 507 

surface by a matrix of epithelial cells, which must be destroyed by an inflamma- 
tion set up in the sac or removed by the knife, before recovery can take place. 
As these cysts may be connected with the sheath of the deep cervical vessels;' com- 
plete removal by operation may be attended by severe hemorrhage unless very 
great care is exercised. When fistula? exist they may sometimes be destroyed 
by passing in a probe which has been dipped in a 10 per cent, nitrate of silver 
solution. If excision of the cyst is not feasible it may be opened and packed 
with gauze. 

Malformations of the Esophagus. 

This malformation is quite rare. The diagnosis is generally made 
probable by the inability of the infant to take or retain an}' feedings, or the 
return of such feedings through the mouth, nose or fistulous tracts. The 
stomach-tube cannot be passed at all or meets an obstruction or stricture. 

Various degrees of malformation occur, such as narrowing in its entire 
length, leaving only a band-like process, openings into the trachea or exter- 
nally into the neck. Blind pouches also have been found. 

Treatment. — . Skilled surgical treatment may avail in the minor de- 
grees of malformation, but the early age and severity of the operative work 
mitigate against success where prolonged procedures are necessary. 

Malformations of the Rectum and Anus. 

A stenosis of the anus may be present, due to abnormal encroachment 
of the skin upon the anal mucocutaneous tissue. The rectum itself may 
be congenitally too narrow. 

The treatment of both these conditions is mechanical dilatation with 
the fingers or a bougie. 

The anus may be imperforate, due to non-absorption of the cutaneous 
envelope, the integrity of the rectum being normal. Treatment of the 
abnormality is by incision and removal of the obstructing tissue. 

There may be an obstruction in the rectum, the anal structure being 
normal : that is. the large intestine may terminate in a blind sac having 
no communication with the anus, or it may have a small fistulous connec- 
tion. Occasionally there is a membranous velum with a very small aperture 
acro-s the rectum. The treatment is surgical. Careful inspection and 
examination of the newly-born by the attendant will reveal the deformity, 
and immediate steps should be taken to obtain surgical correction. 

The time of the passage of the first stool and its size and character 
should always be investigated by the attending physician. Minor degrees 
of stenosis of the rectum or anus are not infrequent in the newly born. 
Although the thin feces of infancy may escape without difficulty, when the 
child grows older and the excreta becomes more solid, stenosis may occasion 
much inconvenience. 



508 



DISEASES OE CHILDREN. 



Hypospadias. 

The anomaly in male genital organs in which the urethra opens on 
the under surface of the penis instead of at the point of the glans, is known 
as hypospadias. This exit may be located at any point on the penis from 
tip to base, and is designated according to location, as glandular, penile, 
peniscrotal, or perineal. In the perineal type, hermaphrodism may be sus- 
pected, as the testicles are often undescended, the penis rudimentary, and 
the scrotum divided by a deep fissure. 

The passage of urine is usually difficult. Dripping of urine from an 
overdistended bladder is the cause of incontinence in these cases. The 

treatment of hypospadias is surgical 
and often is tedious, but experienced 
operators now obtain very satisfac- 
tory results with flap-method opera- 
tions. 

Extrophy (Ectopia) of the 
Bladder. 

This deformity is characterized 
by Ahlf eld as " a fissure in the abdo- 
men of an otherwise well-formed 
fetus, which is lined with a bright 
red, velvet-like skin (the bladder 
membrane), and which is constantly 
kept moist by the urine which 
trickles upon it. Below the fissure, 
in the abdomen and bladder, are to 
be seen incompletely developed ex- 
ternal genitals/' 
The only treatment is plastic surgery, and the results are often quite 
brilliant, although several operations are usually necessary before a satis- 
factory repair is made. 

Congenital Dislocation of the Hip. 

The cause of this deformity is not known, but some cases are doubtless 
due to fibroid tumors in the maternal uterine wall producing a malposition 
in utero. Lange distinguishes three forms: the supracotyloid, the supra- 
cotyloid and iliac, and the iliac. 

The condition is rarely noted in early infancy, as the symptoms are not 
in evidence until the patient begins to walk. The leg is shortened and 




Fig. 153.- 



Congenital deformity of 
the hand. 



CONGENITAL MALFORMATIONS AXD DEFORMITIES. 



509 



flexed on the pelvis, and when the dislocation is bilateral there is a consider- 
able lordosis present when the patient stands erect. If the dislocation be 
unilateral a scoliosis results. A peculiar waddling gait is quite character- 
istic of these cases. When there is much contraction of the adductors the 
lower ends of the femurs cross each other, forming the scissor-leg deformity. 
This, however, is rare. A Eoentgenogram will clear up any question as to 
the diagnosis. A reduction of the dislocation is more readily made when 
the patients have not done much walking, as owing to the shallow aceta- 





Fig. 154. — Double congenital 
dislocation of the hip. 



Fig. 155. 



Intra-uterine amputation 
of the hands. 



bulum it is impossible to keep the femoral head in place unless the patient 
remains in bed. 

Treatment. — The bloodless reduction method advocated by Lorcnz is 
usually selected by the surgeon as offering the best results. A plaster dress- 
ing is applied which must be worn for months, and later massage and exer- 
cises are ordered. This operation should not be delayed too long, as in 
older children good results are rarely secured. 



510 



DISEASES OF CHILDKEN. 



Congenital Absence of the Bones. 

Among the rarer bony deformities there is occasionally seen an absence of 
the radius. This is a bilateral defect, and produces a serious incapacity in the 
physical strength and ability of the extremity affected. An incurvation due to 
abnormal muscular attachments results, as illustrated in the radiograph (Fig. 
156). 

Fig. 154 is a radiograph showing absence of the greater portion of the 
phalanges. 

Fig. 155 shows an absence of the hands beyond the carpals as a result of 
intrauterine amputation. 





Fig. 156. — Congenital absence of the radius. 



Talipes. 
(Club-foot) 

Congenital talipes results from malformation or lack of development 
of the bones about the ankle. A small uterus with deficient liquor amnii 
may produce a talipes by abnormally compressing the parts, the normal 
position of the feet in utero being a talipes varus. 

All acquired talipes are due to pathological conditions ; for example, 
following anterior poliomyelitis or contractions of tissues after extensive 



CONGENITAL MALFORMATIONS AND DEFORMITIES. 



511 



burns or diffuse suppurations, and as the result of the overaction of certain 
muscle groups when the nerve trunk supplying their equilibrants is aifected. 

In fact, any process which will change the normal equilibrium of 
muscle groups about the ankle will produce a talipes. The cause may be 
found in the bony or ligamentous structures or in the muscles. 

Talipes varus is the most frequent variety seen in congenital cases. 
In this form the patient walks on the outer surface of the ankle, the inner 
surface of the foot being raised. 

Talipes equinus results when the heel is elevated and the patient walks 
on his toes. This form results from paralysis of the extensor muscles of 
the leg, with secondary contractions of the muscles of the calf, and occurs 
following anterior poliomyelitis or injuries to the anterior tibial nerve. 




Fig. 157. — Congenital club feet in an infant with a spina bifida. 

In talipes valgus the patient walks on the inner surface of the ankle, 
the outer border of the foot being raised and everted. A paralysis of the 
tibial muscles produces this deformity. 

Talipes calcaneous is rare ; the patient walks on his heel with the toes 
elevated. This deformity arises when the calf muscles are paratyzed. 

Treatment. — In congenital cases daily manipulation of the foot and 
ankle should be instituted at once until the deformity is overcorrected, the 
foot being retained in good position by mechanical means such as a ca?t or 
apparatus. 



512 DISEASES OF CHILDREN. 

In paralytic cases manipulation and massage is indicated, special atten- 
tion being given to the weakened muscle groups, toning them up by the use 
of faradism and friction. A proper splint should be applied to retain the 
foot and ankle in the correct position. Tenotomy and other operative meas- 
ures may be necessary in neglected cases. 

Webbed Fingers and Toes. 

(Syndactylism.) 
In this condition two or more ringers or toes are joined laterally by 
a web, which, if thin, consists mainly of skin, but if thick more or less fleshy 
tissue is present. If the fingers be affected, the web must be divided, care 
being taken to insure full separation to the base of the fingers and the 
separation maintained. If the web be thin the operation consists in incision 
only; but if the web be fleshy, skin flaps must be made and the denuded 
surfaces covered. Webbed toes need not to be treated unless for the 
cosmetic effect. 

Meningocele and Encephalocele. 

Owing to a congenital opening at some part of the skull, a portion of 
the cranial contents may protrude. The defect is most common in the 
occipital bone, in any portion of which the defect may be present, from the 
peripheral part to the center. If it exists in the anterior portion of the 
bone, it may extend to the posterior fontanel; if in the back part, it may 
connect with the foramen magnum. The size of the tumor depends, of 
course, upon the extent of the opening in the bone. Similar defects may 
also be present in the nasofrontal region, and less frequently in the basilar, 
temporal, and parietal segments of the skull. The openings may contain 
meninges alone, meninges with brain matter, or the latter with fluid in the 
interior ; in the latter event the anomaly is termed hydr encephalocele. The 
tumors appear at or soon after birth. 

A meningocele is usually small, with little tendency to increase in size. 
It may be more or less pedunculated ; it presents fluctuation, but no pulsa- 
tion, and is usually reducible. 

In encephalocele there is distinct pulsation, and efforts at compression 
will be accompanied with evidences of marked cerebral irritation. The 
tumor, though not large, has a wide base, and is partly reducible. 

A hydrencephalocele is apt to be large, lobulated, with sometimes a 
distinct peduncle. Pulsation is usually absent in the tumor, which, how- 
ever, is fluctuating and mostly translucent. Compression is not apt to be 
successful in reducing the tumor. Sometimes there is more brain substance 



COXGEXITAL AEALFOHAEATIOXS AXD DEFORMITIES. 



513 



in the tumor than in the cranial cavity, and the infant is then micro- 
cephalic. 

Prognosis. — The prognosis in hydrencephalocele is bad, as the tumor 
usually grows rapidly, and there may be rupture, with immediate death. 




Fig. 158. — Webbed fingers. 




Fig. 159. — Supernumerary thumb. 



In meningocele and encephalocele the prognosis is better, especially if the 
tumor be small. 

Treatment.— Treatment in these cases is of little avail, although the 
withdrawal of fluid and even stimulating injections have been tried. 
33 



514 



DISEASES OF CHILDBED. 



Spina Bifida. 

Owing to congenital failure in the development of the vertebral arch, 
one or more of the laminae may be absent, with resulting protrusion of the 
spinal meninges. The lumbar region of the spinal column is the part 
usually affected. Occasionally, however, we have meningocele or encephal- 
ocele. The tumor is round, fluctuating, and by compression the cerebro- 
spinal fluid can be forced back into the spinal canal. Too severe pressure, 
however, may produce eclampsia or other grave cerebral symptoms. The 




Fig. 160. — Meningocele. 



base of the tumor depends upon the size of the opening, being pedunculated 
if it is small, but more sessile if large. The tumor is usually covered with 
skin, which, however, may be absent, exposing the dura mater. If there is 
not much tissue covering the tumor, transudation may occur through the 
walls or rupture of the sac may take place if growth is rapid. Some portion 
of the lower segment of the cord or the cauda equina is apt to be imprisoned 
in the sac. The extent of the involvement of nerve-tissue can be measured 
by the paraplegia or other evidences of lesion in the spinal cord and nerves. 



COXGEXITAL ALALFOKMATIOXS AND DEFORMITIES. 



515 



Gradual absorption of the fluid ma}' occur, and the child may grow 
up with little inconvenience from the shrivelled tumor. This, of course, 
takes place only when the nerves are not involved. In most cases there is 
a gradual increase in the size of the tumor, with final ulceration or rupture, 
followed by convulsions or coma and death. The fatal ending may also 
come with a gradual emaciation accompanying paraplegia. 

Treatment. — The treatment of small tumors consists in the applica- 
tion of a soft compress to avoid friction and to support the parts. ~\V hen 
the tumor is growing, however, more energetic measures may be tried. The 
simplest procedure is to withdraw the fluid by aspiration, and follow this 




Fig. 161.— Spina bifida. 



with gentle but constant pressure. The fluid must be slowly and cautiously 
removed, for fear of active nervous disturbance and even eclampsia. Injec- 
tions with iodin of various strengths have been tried, but without much 
success. In some cases the tumor can be surgically removed by completely 
excising the sac. This may be successfully accomplished in the peduncu- 
lated variety where the opening in the lamina is small. It should never be 
attempted if there is evidence that the cord or cauda equina may be involved 
in the tumor. Eadiographic examination should be made in all cases in 
which it is proposed to do surgical work, as in this way the operative cases 
often can be separated from the non-operative variety. 



SECTION XV. 
THE COMMONER SURGICAL DISEASES. 



CHAPTER XXXIX. 
THE COMMONER SURGICAL DISEASES. 

Anesthesia. 

The administration of an anesthetic to a child is often rightly viewed 
with apprehension by the practitioner, and questions arise as to the best 
method and safest anesthetic to employ. 

The same phenomena are observed in early life as in adults, but the 
margin of safety is less, and thus the use of any anesthetic should be re- 
garded as a factor by itself and given the consideration it deserves in rela- 
tion to the age, the physical condition of the patient, and the character of 
the operation which is to be undertaken. It should be recollected that any 
anesthetic given beyond its proper limits is a cardiac depressant. 

Choice of Anesthetic. — Ether is preferable if the anesthetist is not 
thoroughly experienced; if the period of insensibility is to be a long one; 
in cardiac diseases and in operations for the relief of obstructed respiration, 
as Ludwig's angina, papillomata of the larynx or deep cervical adenitis. It 
is also to be preferred if the patient must be kept in an erect or semi-erect 
posture. 

Chloroform in the hands of an expert in anesthesia is sometimes prefer- 
able to ether. Children are rapidly brought under its influence, as they 
usually cry and thus inspire rapidly. Plenty of air, constant vigilance, and 
the utilization of the drop-by-drop method, depending on each minim admin- 
istered to acid to the effect, is the proper procedure. 

In minor surgical affections in which only a primary anesthesia is 
required, chloroform is of advantage, as the patient rapidly comes out of its 
influence without the nausea and vomiting which are so often seen with 
ether. Chloroform is preferable if nephritic conditions are present, or a 
possibility, as in suppurative adenitis following scarlatina. Lividity of the 
lips, with an ashen-pale face and weak, slow pulse, are indications that 
should be met by immediately stopping the anesthetic, inducing free 
respirations and by hypodermatic stimulation. 

516 



THE COMMONEB SURGICAL DISEASES. 517 

Gas-ether anesthesia, in the hands of professional anesthetists, is the 
method to be selected for older children, but in infancy and the first years 
of life the nitrous oxid gas is poorly borne and liable to cause suffocative 
cyanosis. 

Anesthesia, according to the method of Schleich, or the spray method 
with ethyl chlorid, is satisfactory in the hands of those accustomed to them, 
but cannot be commended for general use. 

Preparation for Anesthesia. — Feeble children should not be denied 
food for a longer period than three or four hours before administering the 
anesthetic. Often a small amount of a hot liquid, such as thin gruel, will 
be effective in preventing collapse of the infant. The bowels should be 
moved by a soap-suds enema, and in older children a dram or two of licorice 
powder should be given the night before. As the bodily heat is easily dis- 
sipated, especially in infants, they should not be unduly uncovered, and 
artificial heat may be applied during the operation with favorable effect. 
A preliminary stomach washing in cases of intestinal obstruction with 
incessant vomiting should precede the operation. Hypodermocylsis and a 
nutrient enema may also be indicated in certain feeble or anemic infants in 
whom collapse is feared. 

Hernia in Early Life. 

Hernia occurs in young children as a result of arrest or defective devel- 
opment of the fetus, which allows the protrusion of some of the abdominal 
contents through a natural opening. 

Etiology. — Hernia in early life may be in the order of their frequency, 
inguinal, umbilical, ventral, and femoral. 

Inguinal hernia occurs more commonly in boys than in girls, and we 
are inclined to agree with Russell that this form is essentially due to a pre- 
formed sac or an obliterated portion of the vaginal process. Such a sac 
results when a part of the peritoneum coming down in front of the testicle 
as it passes into the scrotum in fetal life fails to be obliterated and sepa- 
rated from the remainder of the peritoneal cavity. Thus oblique or indi- 
rect hernia is congenitally formed. Coley suggests that the terms " con- 
genital " and "acquired" be abandoned and that we adopt instead the 
classification of total or partial funicular sacs. Direct and femoral hernias 
are in the majority of cases acquired, as they rarely result from congenital 
sacs. 

The most common predisposing causes other than the anatomic are 
constipation, pertussis, tympanites, crying, straining, and coughing. 

Symptomatology. — The signs do not differ very materially from 
those found in the adult. A tumor may appear and reappear several times 



518 DISEASES OF CHILDREN. 

before attention is directed to it. The tumor gives an impulse to the finger 
on crying or laughing; it may disappear spontaneously on lying down; 
it may cause discomfort or even pain at this time of life, and if the intestine 
has protruded a sensation of gurgling is felt when the tumor contents slip 
into the abdominal cavity. Strangulation is not common, and when it 
occurs results from constriction at the external abdominal ring, from tough 
and inelastic fibrous bands or rings which may be found within the sac 
(De Garmo), or from fecal impaction. The symptoms of this complication 
are, besides the tumor itself, nausea and vomiting, constipation with abdom- 
inal distention, pains of a colicky character which are increased on urination, 
increased pulse rate, a variable amount of temperature, restlessness, and 
if relief is not obtained at this point vomiting becomes stercoraceous with 
subnormal temperature, and a fatal issue will result. 

Diagnosis.— The differential diagnosis is given on page 452. 

Treatment. — The great majority of children under three years of age 
can be cured by mechanical means. This implies the proper application of 
a suitable truss. This should be made of hard rubber with a slightly con- 
vex pad of the same material, or consist of a water pad covered with imper- 
vious, water-proof material. These are recommended because they can be 
readily adjusted and kept clean. Leather trusses soon become soiled or 
soaked with urine and produce excoriation. The physician himself should 
select and fit the truss ; the spring should be just strong enough to properly 
retain the hernia even when the child cries or strains. It should be applied 
only in the prone position and worn continually day and night. Parents 
should be warned not to unnecessarily remove it unless the child is lying 
down and the hernia meanwhile digitally retained. A cure is generally 
affected within a year, although it is advisable to retain the support for a 
year and a half. If after this time the tumor still protrudes on exertion, 
recourse must be had to operation. 

Children over six years of age are rarely, if ever, cured by the appli- 
cation of a truss. 

The treatment of umbilical hernia has been discussed and illustrated on 
page 14. Operation is indicated immediately in all cases of strangulated 
hernia. It is necessary in hernia complicated with irreducible hydrocele, 
in femoral hernias, and in children over four years of age who have not been 
cured by the application of a properly fitted truss worn over the prescribed 
period. 

The Bassini operation, which is founded upon the etiological factors 
involved in the production of hernia, almost invariably gives most satisfac- 
tory results in competent hands. 



THE COMMONEK SURGICAL DISEASES. 519 

Circumcision. 

Many male infants need circumcision. The operation promotes clean- 
liness and inhibits the formation of the habit of masturbation. 

In cases in which the adhesions about the glans penis have been sepa- 
rated and the prepuce still does not sufficiently retract, circumcision is indi- 
cated. It is certainly necessary in all cases in which the prepuce is tight 
enough to hold drops of urine or when it balloons out on urination. The 
prepuce should be so trimmed that the corona is covered and only enough 
should be cut away so that the prepuce can move freely over the glans. In 
this way its physiological purpose will be preserved. 

This operation should be performed in the early months of life. It 
should be unnecessary to say that surgical cleanliness is to be observed. 
With a pair of hemostatic forceps stretch the prepuce, and insert a director 
between it and the glans. Then incise along the dorsum in the middle line 
to a point just proximal to the corona. Separate all adhesions until the 
coronal sulcus is defined and remove all smegma. Cut away the redundant 
tissue, including both skin and mucous membrane from both sides down the 
frenum. After all the edges have been carefully trimmed put in three or 
four fine plain catgut sutures to prevent any exposure of raw surface. 
Bleeding is slight and probably no ligatures will be required. Use plain 
gauze strips covered with sterile vaselin for a dressing. If the suture mate- 
rial used is non-absorbable, remove the sutures on the fifth day and powder 
the wound with aristol. 

Appendicitis. 

Etiology. — Appendicitis is comparatively rare in early life. In in- 
fancy it is extremely uncommon. Invasion of the lymphoid structure of the 
appendix by bacteria is made possible by traumatism from within or with- 
out, by intestinal parasites, mucous inclusion, or constrictions harboring 
fecal masses. 

From a pathological standpoint the disease in children does not mate- 
rially differ from that found in the adult. It should be recollected, how- 
ever, that the appendix in children is normally not larger in diameter than 
a goose-quill ; that it is more apt to be found in diverse situations, and that 
it normally lies higher in the abdomen. Suppuration takes place more 
readily and localized abscess formations are not unusual. In quite a 
number of our cases, children with appendicitis were willing to walk about 
or sit up even when ulcerative conditions were subsequently found at 
laparotomy. 

Symptomatology. — In the acute inflammatory form the child may 
complain of indefinite colicky pains, which are often attributed by the par- 



520 DISEASES OF CHILDEEN". 

ents to some indiscretion in diet, especially when vomiting occurs early. 
The fever is not high, rarely rising above 102° F. If the patient is walking 
about, he usually stoops, and his movements are made cautiously. After 
being placed in bed he may prefer to lie on his back, drawing up the knees 
to relax the abdomen. Although if asked to do so he may not hesitate to 
turn to either side or extend the thighs. The area of pain may not be 
definitely located by the patient in the right iliac fossa; in fact, he very 
often refers it to the umbilical region. Dysuria is often a prominent symp- 
tom in suppurative cases. 

Examination. — On inspection the contour of the abdomen is usually 
found to be normal, although there may be slight distention observable. 
Palpation, carefully performed, so as not to excite undue muscular effort, 
may elicit some resistance and tenderness in the right iliac fossa. In chil- 
dren it is seldom that a definitely localized spot of tenderness is found over 
McBurney's point. In thin subjects, however, it may be possible to defi- 
nitely locate the inflamed appendix. If the diagnosis is still in doubt, bi- 
manual rectal examination should be made according to the method 
described on page 47. A low grade of leukocytosis is usually found in 
this type. 

Such a case of appendicitis may subside under medical treatment, but 
recurrences are almost sure to follow at some future time, making the prog- 
nosis graver than if operation is performed at once or in the interval. 

The suppurative form, with a tendency to perforation at or near the tip, 
occurs more commonly, and the symptoms are more severe. The pain may 
come on suddenly with fever, nausea, and vomiting. Constipation and 
tympanites occur, and the patient generally seeks his bed, satisfied to lie 
quietly in the recumbent posture. The legs are drawn up and the patient 
localizes the pain more definitely to the right iliac fossa. Temporary anuria 
or dysurea may be present. The temperature varies between 101° and 103° 
F. and rarely rises above this point; the fever may not reach higher than 
101° F. The pulse rate is increased, especially so if perforation takes place. 
Gangrenous changes may occur and may be suspected if the subjective or 
constitutional signs are more marked. 

Examination. — On inspection, the attitude of the patient with the 
knees drawn up, the facies showing distress, the coated tongue and the dis- 
tended abdomen, with suppressed abdominal respiration, should be sugges- 
tive. On palpation of the right side the muscular rigidity is marked and 
a distinctly painful area of tenderness may be mapped out. In some cases 
the tumefaction or mass can be quite easily felt. Rectal examination should 
confirm these findings. Eepeated blood examinations will show varying 
percentages of polynuclear elements ranging from 85 to 95 per cent. If 
peritonitis has resulted, the abdominal rigidity is increased and vomiting 



THE COMMONER SURGICAL DISEASES. 521 

again occurs, the abdomen is distended with gas, obscuring the liver dull- 
ness. "When the peritonitis is localized about the caput coli the inflamed 
appendix may be walled off from the general cavity. This is indicated by 
a diminution of the general symptoms. 

An abscess may form within this area from perforation, gangrene or 
rupture of the appendix. Fluctuation may be obtained, but even before this 
a sudden drop in the temperature curve points to a focus of pus. A differ- 
ential leukocyte count will also act as corroborative evidence when the 
percentage of polymorphonuclear leukocytes is greater than eighty. 

Diagnosis. — Cases presenting the classical symptoms of pain in the 
right iliac fossa, with rigidity of the right rectus muscle, tumefaction, fever, 
and vomiting, should occasion little or no difficulty in diagnosis. Exam- 
ination under a general anesthetic may sometimes be necessary in doubtful 
cases, especially if a skilled surgeon is not at hand. Intestinal obstruction 
is to be differentiated by the absence of initial fever, the presence of a 
palpable sausage-shaped mass, tenesmus, and discharges of blood and mucus. 

Xot infrequently a pneumonic process involving the base of the right 
lung causes pain which is referred to the ileocecal region, and the unwary 
may mistake this for appendicitis. 

Prognosis. — The tendency toward suppuration and the development 
of general peritonitis make this disease a grave one in early life. The 
mortality, however, will be distinctly lessened when early diagnoses are made, 
followed by prompt surgical intervention. 

Treatment. — The medical treatment of appendicitis should consist in 
immediately placing the patient in bed, allowing him to assume a position 
of comfort. A light ice bladder is placed over the point of greatest tender- 
ness. The bowels should be moved with a soap-suds enema. A liquid diet, 
consisting of milk, ice cream, and thin gruels, is given if the vomiting per- 
mits. The question of operation should be left to the judgment of a com- 
petent surgeon. 

Children bear the operation well, and, unless the circumstances contra- 
indicate it, immediate operation is to be preferred to the chances of perfora- 
tion or general peritonitis. 

Intussusception. 

(Invagination.) 

This very frequent form of intestinal obstruction in children is caused 
by a prolapse of a portion of intestine into the lumen of the adjoining bowel. 

While other causes, such as volvulus, Meckel's diverticulum, band?, and 
foreign bodies, may produce intestinal obstruction, they occur so rarelv that 
thev need not be considered here. 



522 DISEASES OF CHILDREN. 

Etiology. — We are inclined to believe that the condition can be ac- 
counted for by irregular peristaltic action taking place in a gut, the walls 
of which are thin and undeveloped and only loosely held by mesentery. 

The exciting cause may be undiscoverable. We have seen it in breast- 
fed infants who appeared healthy in every way. Overloading of the intes- 
tine, producing fermentation, colic and an irritative form of diarrhea, may 
induce it. Constipation, tenesmus, polypi in the intestinal wall, appen- 
dicitis, and cathartic drugs have been held responsible for its onset. It 
occurs more frequently in males and the majority of cases occur in poorly 
nourished children in the first year of life, the fourth to the sixth month 
being the time of greatest incidence. 

Symptomatology. — The onset is sudden and acute in the majority of 
cases. Only in such situations as the rectum or low down in the colon may 
the symptoms come on at all gradually. An infant apparently healthy may 
suddenly begin to cry violently with pain which is usually regarded as 
colicky in nature, and the extremities may be kept incessantly moving. 
Vomiting soon occurs, and the child's appearance changes. The face is 
pale, showing marked evidences of distress and prostration. The first move- 
ment of the bowels after the intussusception may contain a slight amount 
of fecal matter ; thereafter the movements consist only of blood and mucus, 
which are passed with some tenesmus. The vomiting, which is almost pro- 
jectile, occurs at very frequent intervals. After the stomach contents have 
been emptied, bile-stained mucus or even fecal matter may be vomited in the 
final stages. There is little or no fever, but the pulse is extremely rapid and 
thready. On examination of the abdomen a sausage-shaped tumor may be 
felt, which, if firmly palpated, may feel harder. This tumor may be found 
in different situations, but generally is found in the left iliac fossa along 
the line of the colon. Bi-manual rectal examination may confirm its pres- 
ence. In some instances it may protrude from the rectum and may be mis- 
taken for a prolapse. It must not be forgotten that intussusception can 
occur without the presence of a palpable tumor. Sometimes a depression 
or flattening in the opposite iliac fossa is observed. Unless relief is ob- 
tained the prostration becomes more intense, while subnormal temperature 
and death may ensue from exhaustion. Cases of spontaneous reduction and 
relief by gangrenous sloughing of the intussusceptum have been reported, 
but are so rare as to merit recognition only as curiosities. 

Diagnosis. — This may be founded upon the following symptoms: 
The sudden onset, paroxysmal colicky pain, vomiting, prostration, with 
discharges of blood and mucus without fecal matter. 

In our experience dysentery is most often confounded with intussus- 
ception. The presence of some fecal matter in the stools, the constant fever, 



THE COMMONER SURGICAL DISEASES. 523 

and the moderate vomiting, with prostration only proportionate to the 
severity of the disease, should distinguish the conditions. It should not be 
forgotten that there may be periods of comparative comfort in the early 
stages of the obstruction, which may disarm suspicion. 

Prognosis. — Unless the condition is promptly recognized and imme- 
diate treatment instituted, a fatal issue may be expected. The mortality 
statistics vary from 60 to TO per cent. The younger the infant the graver 
the prognosis. 

Treatment. — An attempt and only one should be made to reduce the 
intussusception if the diagnosis is quite certain within a few hours after 
the onset of the acute symptoms. It may then be successful, especially if 
the invagination is in the colon. 

The child is placed on its back, the buttocks elevated, and a warm 
saline solution from a two-quart fountain bag, held four feet above the 
patient, is allowed to distend the gut. The fluid should be retained by 
holding the buttocks firmly together. A long, large catheter is preferable 
to the ordinary hard-rubber tip. While the child is in this position gentle 
manipulations to assist the reduction may be made. If the result is suc- 
cessful the tumor disappears with a gurgling intestinal sound. Undue 
efforts in this direction should not be made. If reduction is unsuccessful 
or the case of longer standing immediate operative interference is demanded. 
A preliminary stomach washing and stimulation hypodermatically in the 
form of strychnin or brandy, will better prepare the patient to withstand 
operative interference. 

Acute Peritonitis. 

In the New-born. — The diagnosis of the acute forms in infancy are 
too often made only at necropsy. This is so because of the uncommonness 
of the affection, the meager history obtainable, if any, the lack of distinctive 
physical signs, and the inability of the patient to relate subjective symptoms. 

Fortunately, acute peritonitis is not a frequent occurrence among 
children, although in the new-born it is not as rare as is commonly sup- 
posed. Through the umbilicus, or skin, pathogenic bacteria may gain 
entrance and cause peritoneal infection. 

The streptococcus, and the bacterium coli communis can be held 
responsible for the majority of the cases occurring in the new-born. W nen 
a general sepsis results the diagnosis is not as difficult as when the infection 
is localized in the peritoneum. 

Symptomatology. — In the new-horn, the disease must be considered 
•when there is a localized umbilical infection followed by a sudden abrupt 
change in the infant's condition. The extremely rapid gasping breathing 
mav first attract the attention of the attendant. The infant cannot or 



524 DISEASES OF CHILDREN. 

will not nurse, the temperature is persistently high, 104° to 105° F. with 
a rapid weak pulse. The position assumed by the infant is one of tension. 
Its legs are drawn up and pain is sharply elicited by attempts to even gently 
move the legs. The breathing if closely observed is seen to be mainly costal 
in type and extremely shallow. The distress caused makes abdominal palpa- 
tion almost impossible. The constant rigidity encountered is quite char- 
acteristic. The urine is almost entirely suppressed. Pallor soon becomes 
marked, and death usually results in two or three days. 

In Early Life. — A similar train of symptoms occurs in the early 
years of life in peritonitis resulting from disease processes in other parts 
of the body as appendicitis, intussusception, perforation, traumatism, 
strangulated hernias, lung involvement, or following the acute infectious 
diseases. Besides the streptococcus, we have the pneumococcus, gonococ- 
cus, colon bacillus, or the ordinary pus organisms as etiological factors. 
Pneumococcic and gonorrheal peritonitis are almost distinctively diseases 
of childhood. 

The diagnosis is likely to be obscured by the underlying affection. The 
medical attendant is likely to center his attention on the primary disease and 
is not attracted by the insidious train of symptoms in the abdomen. Invasion 
of the peritoneum is evidenced by sudden high increase of temperature, or 
by a subnormal temperature with signs of collapse, extreme pallor, feeble 
rapid pulse, 120 to 180, and cold extremities. The eyes are fixed and 
sunken, nausea and finally bile-tinged vomiting may follow. Any attempt 
to give medication or food by mouth is apt to be followed by vomiting. 
Constipation is the rule. The postural picture is the same as that just 
described for the new-born, except that a tympanitic condition is more apt 
to occur and the young child may feebly attempt to ward off any attempts 
at palpation of the abdomen. The pain may be referred to the navel or 
localized in the iliac fossa. The leukocytes are moderately increased. 

Peritonitis of gonorrheal origin should be suspected where such 
a train of symptoms in a female child are accompanied by a specific 
vulvovaginitis. 

Pneumococcic peritonitis may result from any pulmonary disease, 
and especially from an empyemic process. It occurs here probably by direct 
infection through the lymphatics of the diaphragm. Hematogenous infec- 
tion seems to be the usual mode, since pneumococcic meningitis and abscess 
formations are not unknown. Since the exudation of pus is in this variety 
considerable in amount, the diagnosis is more readily made by the finding 
of accumulated fluid in the lower segment of the abdomen. If recognized 
early and proper measures of rest and posture are instituted, encapsulation 
is apt to occur, and the prognosis is correspondingly improved. Paroxysmal 



THE COlIilOXEB SURGICAL DISEASES. 525 

pains, chills, vomiting, severe diarrhea, and abdominal distention are noted 
in the early days of the disease. On palpation, there may be fluctuation, 
corroborated by dullness on percussion. Pneumococcic infection of the 
peritoneum, though a dangerous disease, is not necessarily fatal, as the pus 
may discharge through the umbilicus. If, however, surgical measures are 
not instituted at the beginning, rapid emaciation and prostration usually 
take place. Diffuse suppurative peritonitis may then result, and a serious 
prognosis is inevitable. The diagnosis as to the exact form can only be 
made by examination of the pus which will show the presence of the 
diplococcus pneumoniae. 

Diagnosis. — The diagnosis in older children with a well-marked train 
of symptoms is not so difficult. In infancy it is often extremely puzzling 
and can often be made only by a process of exclusion. The symptom of 
pain cannot always be depended upon, as it is often relatively less than in 
adult life. 

From intestinal obstruction it is not always easy to differentiate peri- 
tonitis, but the lesser amount of abdominal tenderness, absence of fecal 
vomiting, and the passage of some gas or feces may be of assistance. It 
should not be forgotten that these conditions may be combined. 

Diaphragmatic pleurisy, or even pneumonia, when the pain is referred 
to the abdomen may occasion a mistake, if a complete physical examination 
is not made. 

Prognosis. — In infancy it is invariably bad. In children peritonitis 
must always be regarded as a grave affection, although the encapsulated 
forms offer some little hope. If a perforation has taken place or if the 
process is general a fatal issue is to be expected. The gonorrheal variety, 
especially in older children, has a better prognosis. 

Treatment. — An early diagnosis will be of value to the patient if 
prompt measures are taken to insure bodily and intestinal rest. If the 
case is seen very early, calomel or a saline may be given, before the appli- 
cation of an ice-coil. Paregoric for young children and codein hypodermati- 
cally for older cases will be required to alleviate the pain and to inhibit 
peristalsis. No attempt should be made to feed the patient. Pieces of 
ice or sips of ice-water to which brandy has been added are grateful and 
often allay vomiting. Hypodermoeiysis and stimulants may be required 
for the pulse. 

The surgeon should be consulted as early as possible and decide as to 
the feasibility of operative interference. 

Ascites. 
By ascites is meant the condition produced by nn effusion of serum into the 
peritoneal cavity. It may occur as a secondary condition in peritonitis in any 
of its varieties. In chronic nephritis and in certain blood diseases. Obstructions 



52<5 



DISEASES OE CHILDREN. 



to the portal circulation, and chronic diseases of the heart and lungs may also 
produce ascites. 

Diagnosis. — The physical signs differ in nowise from those obtained in the 
adult, and therefore may be omitted here. 

Chylous Ascites. — The diagnosis of this rare form is made only after aspira- 
tion. Several cases have lately been reported. Its causation is unknown, but is 
attributed to some obstruction or disease of the thoracic duct. The ascitic fluid 
is milky white in color and usually contains fat globules in a fine emulsion. 
Leukocytes and a few red blood-cells may be found. 

Treatment. — Withdrawal of the fluid for the relief of pressure symptoms 
may be necessary in advanced cases, otherwise the treatment resolves itself into 
measures directed to the primary condition. 

Ischiorectal Abscess. 
These abscesses are more commonly observed in children of poor nutrition 
who have been reared under unhygienic circumstances. Through the lymphatic 
channels of the rectum, the perirectal lymph nodes become infected and form 
an abscess. The diagnosis is made on inspection and palpation or by rectal 
examination. 

Treatment. — Free incision, cleansing with 
antiseptic solutions, such as the peroxid of hy- 
drogen and stimulation with a 2 per cent, silver 
nitrate solution, or packings saturated with 
balsam of peru and castor oil, one to ten, will 
effect a cure. In tuberculous children these 
abscesses may be exceedingly intractable and do 
not tend to heal until the general nutrition is 
improved. 

Rectal Polypus. 

The growths are commonly found low down 
in the rectum and attached by a pedicle. Rarely 
are they multiple and sessile. On examination 
they are found to be adenomatous or fibromatous 
in structure. They vary in size, but rarely are 
larger than a hazel nut. 

Symptomatology. — The case is usually 
brought to the attention of the physician because 
of intermittent hemorrhages which may or may 
not be accompanied with tenesmus. Sometimes 
only the fecal masses are blood-streaked. If 
the straining is persistent prolapse of the rec- 
tum may result. Rectal examination is indi- 
cated with the above train of symptoms and the 
source of bleeding will then be found. 
Treatment. — The removal of the pedunculated tumors is easily accomplished 
by twisting the pedicle or passing a ligature about it before cutting it. If it 
cannot be withdrawn the use of an anesthetic and a speculum will be required 
so that bleeding from the stump may be arrested. 

Fissure of the Anus. 

This may occur following the passage of a hard constipated movement. It 
is also seen in children suffering from marasmus, syphilis, and eczema. Occa- 
sionally a fissure is produced by undue dilatation of the sphincter by injections, 
suppositories or rectal examinations. Pain, some bleeding, and tenesmus are the 
signs which should lead to a careful inspection of the anal region. 

Treatment. — The buttocks should be separated as widely as possible and 
the fissures touched daily with a solution of silver nitrate, dram one to the ounce. 
If constipation is present laxatives or enemas with careful oversight of the diet 
will promote healing. In intractable cases the rectum should be gently dilated, 
a feat which is easily accomplished in children by the successive introduction of 
well-greased fingers beginning with the smallest. This procedure should cause 
little or no pain, and generally effects a cure. 




Pig. 162. — Characteristic shape 
of belly in ascites. ( Cabot. ) 



THE COMMONER SURGICAL DISEASES. 



527 



Prolapse of the Anus and Rectum. 

Prolapse of the rectum is more commonly observed in children of the 
second and third years of life. The protrusion may be partial, being only 
a simple eversion of the mucous membrane, or complete, in which all the 
layers of the rectal wall protrude outside of the sphincter, sometimes for 
one or two inches. 

Etiology. — The causes provoking this condition are those accom- 
panied by much tenesmus, such as colitis, straining in chronic constipation 
or diarrhea, or with calculi. Rectal polypi will often lead to a prolapse. 
A neglected cause is the use of stooling chambers too large to give proper 




Fig. 163. — Adhesive plaster dressing for prolapse of the rectum. 



support to the buttocks. Anemic and badly nourished children are par- 
ticularly prone to this affection, as in them the pelvic musculature is 
incompetent. 

Symptomatology. — The protrusion of a dark red cone-shaped mass 
covered by transverse folds of mucous membrane, and with a rounded open- 
ing at the apex of the tumor is diagnostic. In some cases blood-streaked 
mucus soils the clothes. The mass can usually be readily replaced, but the 
protrusion will be apt to recur after straining or coughing or with the next 
defecation unless preventive measures are taken. 

Diagnosis. — Although the diagnosis is generally easily made, one 
of us has seen a mistake made in a case of intussusception in an infant in 
whom the invaginated gut protruded from the rectum. 

Treatment. — This consists in replacing the tumor and retaining it. 
A piece of gauze covered with vaseline is placed over the tumor, and by 
gentle pressure exerted over the entire mass the prolapsed tissues will slip 
back into place. If the reduction has been delayed too long it may be 
necessary to apply ice or ice-cold cloths for a short period and then to repeat 
the above manipulation. 



528 



DISEASES OF CHILDREN. 



Two wide bands of adhesive plaster applied over the buttocks, above 
and below the anus, so as to exert firm pressure and give added support to 
the pelvic attachments, will retain the prolapse. Local conditions, such 
as constipation, colitis, and polypi, should be remedied and conditions of 
malnutrition corrected before a hope of permanent cure can be entertained. 
The child must lie on a bedpan during defecation and the movement 

should be induced by a mild enema 
of oil or glycerin. He should be 
taught to avoid excessive abdominal 
pressure. Local applications of as- 
tringents, such as the fluid extract of 
krameria or tannic acid ointment, 
are helpful. The diet should be so 
regulated during the cure that the 
movements passed will be soft and 
unformed. Mild laxatives as cascara 
or the milk' of magnesia may be 
necessary. 

In exceptionally severe or neg- 
lected cases, the prolapsing mucous 
membrane must be linearly cauter- 
ized by the thermocautery to pro- 
duce cicatrix, or a radical operation 
may be necessary. 

Malignant Tumors in Children. 

While almost any form of be- 
nign or malignant growth may occur 
in early life, it may be said that 
carcinoma is quite rare, while sar- 
coma is much more frequent. When 
this form occurs in children it is 
much more malignant than in adults. 
Three types are known, the round cell, spindle cell and giant cell 
varieties, the first being the most malignant. 

Nevi sometimes become sarcomatous, but the bones, kidney, testes, and 
epidermal tissues are more frequently involved. The ends of the long 
bones showing a special predilection. 

Sarcoma of the face often causes confusion of diagnosis. Sarcoma of 
the kidney which is often congenital may attain an immense size. Their 
growth is exceedingly rapid and they are never bilateral. (See p. 442.) 




Fig. 164 



Sarcoma of the lower 
abdoniGn, 



THE COMMONER SURGICAL DISEASES. 



529 



Diagnosis. — The shape and size of the tumor is determined by its site 
and the tissues involved. The tumors are at first freely movable if located 
in soft tissues; they are seldom hard and firm; on the contrary, they may 




Fig. 165. — Osteo-sarcorna of the temporal bone 




Fig. 16G. — Sarcoma of the face. 



even feel fluctuant. Particularly suggestive are the superficial veins, usu- 
ally dilated, which are found over these tumors. The skin covering them 
may be somewhat dusky or bluish in color. 
34 



530 DISEASES OF CHILDEEN. 

Metastases occur by way of the blood stream, consequently adjacent 
lymphatic glands are not involved. 

Treatment. — Sarcoma is of relatively rapid growth and extension 
and this fact makes an early diagnosis essential, as complete removal is the 
only treatment. 

Coley's fluid which contains the toxins of streptococcus, erysipelatosus 
and bacillus prodigiosus can be tried in inoperable cases with the hope of 




Fig. 167. — Sarcoma of kidney. 

arresting the growth. It is administered hypodermatically the injection 
being made into the periphery of the growth. Begin with injections of 
one minim, and as tolerance is produced the dose may be increased to five 
minims twice a day. 

In certain situations, as on the face, considerable pain is experienced 
unless fairly powerful analgesics are given. 



SECTION XVI. 
DISEASES OF THE EAR AND EYE. 



CHAPTEE XL. 
DISEASES OF THE EAR. 

General Considerations. 

Familiarity with the anatomy of the organs and structures of hearing, 
at least in a general way, is incumbent upon those whose practice is among 
infants and children. 

At birth the external bony canal has not developed and there is present 
only a cartilaginous canal. The walls of the soft meatus may in infants 
be found almost in contact so that the tympanic membrane is examined 
with difficulty unless these are separated. In structure the walls of the 
meatus are thicker than in the adult. The vault of the tympanum is dis- 
proportionately large and may have an incomplete tegmen. The Eustachian 
tube is shorter, horizontal, and relatively wider, the pharyngeal outlet being 
on a line below the hard palate. The mastoid process is entirely undeveloped 
at birth, and it is not until puberty that it assumes the adult characteristics. 
The antrum, however, is developed, surrounded by thin bony walls. The 
close relationship of the sutures and the lateral sinuses to these structures 
accounts, in greater part, for the frequency of intracranial complications in 
early life. 

Otoscopy. 

For this purpose a good light and a properly shaped speculum (see 
Fig. 168) is necessary. The child's arms should be fastened to its side by 
wrapping in a large sheet or towel : the attendant holds the child with one 
arm thrown about the chest and with the other on top of the head keeps 
the ear in the right direction. By drawing the auricle downward and 
backward a better view can be obtained. Accumulations of wax or exfolia- 
tions of the drum membrane must first be removed by the use of a fine 
cotton-tipped applicator before a good view of the drum can be had 
(McKernon). 

If the ears of normal children are first examined the method and a 
working knowledge of the normal appearance will soon be obtained and 
otoscopy will then be more frequently made a part of the routine examina- 

531 



532 



DISEASES OE CHILDREN. 



tion, and aural complications will go unrecognized less frequently, and 
more serious complications, such as mastoid involvement and deaf-mutism, 
prevented. The descriptions in this section are for diagnostic purposes 
and the reader is referred to books on this special subject for details of 
treatment. 

Otitis. 

This is very common in early life, occurring almost always secondarily 
to the acute exanthemata, gastroenteritis, influenza, adenoid vegetations, 
and chronic rhinitis. Less commonly it may follow such diseases as typhoid 
infection, diphtheria, acute follicular tonsillitis, and cerebrospinal menin- 
gitis. It may also be induced by improper methods of nasal irrigation or 




Fig. 168. — Properly shaped ear-speculum. 



by violently blowing the nose, the bacteria in the nasopharynx being forced 
into the Eustachian tube. 

According to Liebman, the streptococcus is most frequently found 
(52 per cent.), streptococcus mucosus next in frequency (8 per cent.), then 
the pneumococcus ( 6Vio per cent. ) . 

Symptomatology. — Unfortunately, in many instances otitis occurs 
during the course of an illness, as, for example, in measles, and unless daily 
otoscopic examinations are made, the first intimation of the process is a 
discharge from the external ear. If after the acute symptoms of the pri- 
mary disease have subsided a sudden and rather constant elevation of 
temperature, with or without earache, occurs, otitis should be suspected. 



DISEASES OF THE EAE. 533 

In some cases rupture takes place even without elevation of temperature. 
When in infants there is restless sleep with sudden unexplainable outcries, 
pulling at the ear, with pyrexia higher at night, inflammation within the 
ear should certainly be thought of. Older children who are able to localize 
and speak of their pain describe it as " stinging " in character. The pain 
comes on at intervals and is worse toward evening and during the night. 
Otoscopic examination in these cases will disclose a much reddened, swollen, 
or bulging membrane. If the process has not advanced to the point of 
actual suppuration there may only be found a crescentic area above Shrap- 
nell's membrane with absence of the normal shining appearance of the 
lower half. 

If the perforation has occurred, the opening is usually seen in the 
posterior and lower quadrant. The discharge may be serous, seropurulent, 
or purulent in character. Chronic otitis media, sinus thrombosis, and men- 
ingitis sometimes follow. In most of the cases, however, following spon- 
taneous rupture or incision of the membrane the discharge after a time 
ceases, healing takes place and restitution to normal occurs, often with little 
or no disturbance to the hearing. 

Treatment. Prophylactic. — Daily examination of the tympanum in 
the course of the acute infectious diseases, the removal of adenoid growths 
and hypertrophied tonsils, and the inculcation of habits of cleanliness, 
such as the nasopharyngeal toilet (see p. 73), will do much to prevent the 
involvement of the ear. 

General. — Early incision of the drum membrane should be practiced 
in thp acute cases if the condition of the membrane warrants. Hot irri- 
gations of saline solution at 110° F. with a fountain bag held two feet 
above the ear, give considerable relief, and in the milder cases the symp- 
toms may entirly subside under this form of treatment. Chronic condi- 
tions require copious irrigations with a warm solution of (1/10,000) 
bichlorid of mercury several times a day. It is best to refer these cases 
to the specialist for more radical treatment if they do not show improvement 
after a few weeks. 

Mastoiditis. 

This most frequently results as a complication of acute or chronic 
middle-ear suppuration and the same etiological factors as given under the 
article on Otitis concern us here. The anatomical structures as outlined 
in the general consideration and the greater tendency toward necrosis of 
bone in earlv life favor the involvement of the mastoid process. 



534 DISEASES OF CHILDKEN. 

Symptomatology. — The symptoms appear after a variable time dur- 
ing the convalescence following an artificial or spontaneous rupture of the 
drum. A sudden or gradual pyrexia may be the initial symptom. This, 
as a rule, is not high, but continues several days, reaching its highest point 
in the evening. Otoscopy, if there has been a previous perforation, may 
show a decrease in the amount of discharge, but the pus may show that 
some retention in the deeper structures has taken place by appearing in 
drops after cleaning the canal. Sometimes there is seen prolapse and 
bulging of the superior and posterior portion of the canal wall. Eestless- 
ness with frequent periods of crying, especially at night, is present in most 
of the cases. Occasionally the temperature reaches 104° or 105° F. in 
the evening, and the lymph-glands in the neighborhood are swollen. The 
tissues over the mastoid may become edematous and the auricle is pushed 
out from the scalp. In unrecognized cases a perimastoid collection of pus 
takes place, especially in infants, and pressure over this tumefaction causes 
a discharge of the pus which has collected in the external canal. Meningeal 
symptoms may appear or in neglected cases the cerebral symptoms may 
predominate and obscure the diagnosis. 

Treatment. — An early diagnosis is imperative in mastoiditis, for it 
is only by the radical operation which drains the middle ear that the mortal- 
ity in this serious disease may be lowered or more serious complications, 
as infection of the jugular bulb, avoided. 



Infective Cerebral Sinus Thrombosis. 

{Jugular Bull Infection.) 

The most frequent cause of local infection of the cerebral sinuses is 
suppuration in the middle ear and mastoid cells. A general septicemia as 
.a result of aural complications may also produce sinus thrombosis through 
the general circulation. Streptococci are most frequently found to be the 
direct cause of the infection. 

Symptomatology. — The disease should be considered if there is a 
sudden rise of temperature in a patient who has a discharge from middle- 
ear disease. This fever is extremely irregular, septic in character, rising 
ofte^ to 105° or 107° F., with remissions to the normal or subnormal. The 
pulse rate is correspondingly high, the infant is at first highly irritable 
and restless and soon becomes apathetic and finally stuporous. There may 



DISEASES OF THE EAR. 



535 



be evidences of meningeal involvement with vomiting and convulsions, and 
pain in the cervical region. If the disease has resulted from the mastoid 
there may be edema in this region, and perhaps, a clot in the jugular vein. 
The percentage of polynuclear elements is high, ranging from 80 to 90 per 
cent. 

Prognosis. — This is extremely unfavorable. A fatal issue usually 
results in a few days unless operative interference is successful. 

Treatment. — Early diagnosis followed by prompt operative procedure 
is the only recourse. Eecent reports show encouraging results. 




Fig. 109. — A serviceable electric auroscope particularly adapted for children. 



CHAPTEE XLI. 

THE COMMONER DISEASES OF THE EYE. 

Foreign Bodies. — Foreign bodies are frequently caught under the 
eye-lids of children, and if not washed away by their own tears, which are 
usually copious, they should be quickly removed to prevent inflammatory 
changes. The upper lid can be everted easily if the child is prone and 
correctly held to prevent interference. The foreign substance can usually 
be easily removed by a fine probe, the end of which has been wrapped with 
a few strands of absorbent cotton. Metallic substances may require local 
anesthesia, which is accomplished with two drops of a 2 per cent, solution 
of cocain. If the particle is not readily removed, the patient should be 
referred to a properly equipped ophthalmologist. 

Blepharitis. — This is often observed in tuberculous, anemic, or poorly 
nourished children, especially when they have a dermatitis elsewhere on the 
body. The secretion as it dries produces further excoriations and aggra- 
vates the trouble. Treatment should be directed to the general condition, 
improving the nutrition by proper diet, cod-liver oil and iron tonics for 
the anemia. General cleansing baths daily with bicarbonate of soda will 
prevent reinfection. Locally, the eye-lids are bathed with a 2 per cent, 
boric acid solution until all the crusts are removed and applications of an 
ointment of yellow oxid of mercury (1/100) are then made morning and 
night until a complete cure is produced. 

Conjunctivitis — Acute. — Injuries and the infectious diseases pro- 
duce acute inflammations quite readily in children and the mucoid secre- 
tions are apt to be more profuse than in adults. The eye-lids should be 
gently separated and the secretions flushed out. Microscopical examina- 
tion of a purulent secretion should be made to determine the possibility of 
infection by the Klebs-Loefner bacillus or the gonoccoccus of Neisser. A 
careful search should be made for foreign bodies. If there is no secretion, 
applications of a 2 per cent, warm boric acid solution every fifteen minutes 
may suffice for a cure. If the secretion is purulent, argyrol in 12 per cent, 
solution (freshly prepared) may be ordered or silver nitrate (1/100) may 
be applied by the physician and quickly flushed out with sterile salt solu- 
tion. Ice-cold applications are often necessary and should be freshly applied 
every ten minutes until the inflammation subsides. A drop of atropin 
sulphate (1/200) may be necessary two or three times a day to procure 
rest for the eye. 

536 



THE COMMONER DISEASES OF THE EYE. 537 

Diphtheritic. — The membrane is tenacious, with an absence of secre- 
tion and much exudation and edema in the eye-lids. The extreme rapidity 
of the involvement and the presence of a possible nasal diphtheria should 
excite suspicion. The treatment is that of diphtheria elsewhere. An 
injection of 10,000 units of antitoxin should be given, and locally the eye 
should be flushed with boric acid solution and kept cold with ice com- 
presses. Protecting the sound eye from infection may be accomplished by 
the use of a shield or the instillation of a 25 per cent, solution of argyrol 
every two hours. 

Chronic. — A careful examination for ocular defects should always be 
made in these cases and the child's habits as to study, etc., inquired into. 
Xot infrequently the condition is improved by appropriate general treat- 
ment or a change from urban to rural life. Locally, astringent applications 
of zinc sulphate (1/250) or silver nitrate (1/500) may be made by 
the physician several times a week and one of the organic silver salts sup- 
plied for home use, as argyrol in ten per cent, solution one or two drops, 
twice a day. Internally the syrup of the iodid of iron is often of assistance. 

Trachoma (granular conjunctivitis). — Eoutine examination of the 
school children in Xew York City has brought to light many cases of 
chronic conjunctivitis which are termed trachomatous. The condition 
occurs in several children of a family and certainly appears to be of a 
microbic nature. Ordinarily the type seen is mild in character and is often 
classed as granular conjunctivitis. The heaped-up granulations and deposits 
are plainly seen when the lids are pulled down. The upper lid should also 
be everted and examined. Marginal ulcerations may occur if the disease 
is allowed to run its course untreated. 

Treatment should be proportionate to the severity of the condition. 
Prophylactic measures to protect other children in the family and school 
should be insisted upon, such as individual towels and wash cloths. Con- 
stant supervision and treatment will finally eradicate the condition and 
lessen the host of cases now in our schools. 

Locally, a solution of zinc sulphate (1/250) or the cupric stick may 
be used by the physician several times a week on the granulations. A 
solution of bichlorid of mercury (1/5000) or argyrol 10 to 20 per cent, 
may be ordered for home use, one drop being instilled twice a day in each 
eye. Severe cases will require the expression operation with forceps under 
a general anesthetic. 

Chalazion. V chalazion is a cyst which results from retention products of 

the Meibomian srlands. There is rarely any pain, although discomfort is com- 
plained of by older children. They are generally excised if they tend to recur. 

Hordeolum or stye is found on the margin of the eye-lid and acts like a 
furuncle on any other part of the body. The evacuation is hastened by hot 
applications and early incision. 



538 DISEASES OF CHILDREN. 

Strabismus. — Strabismus (squint) may be either paralytic or non- 
paralytic. Paralytic squint is due to partial or complete paralysis of one 
or more of the muscles of the eye. It may be congenital, or it may be 
acquired from trauma or from an acute infectious disease, such as diph- 
theria or cerebrospinal meningitis. It may also result from photophobia, 
phlyctenular keratitis, and interstitial keratitis. 

Non-paralytic squint in children is more common, and it is usually 
convergent. Contrary to a common belief, children seldom " grow out , ' 
of it. If neglected, the squinting eye usually becomes amblyopic. Neg- 
lected " cross eyes " are responsible for many blind eyes in adults. If 
prescribed sufficiently early, correct glasses accomplish cures in many of 
these cases. Even young children can wear glasses without danger. 

Keratitis. — This is usually found in tuberculous and rachitic children, sec- 
ondary to other ocular and dermal conditions, although syphilis itself causes the 
interstitial or parenchymatous variety. 

The condition begins with congestion and involvement of the tissues about 
the cornea. There is photophobia, orbicular spasm, pain, and an abnormal flow 
of tears. Later a haziness is observed and vision is impaired. The superficial 
lesion, if untreated, soon invades the cornea, and ulceration or even suppuration 
results. 

The phlyctenular variety is most frequent in early life. Beginning with 
small vesicles on the palpebral conjunctiva, it spreads to the ocular conjunctiva 
and here forms characteristic ulcerations which may leave permanent opacities 
of the cornea. Treatment should be directed to the underlying constitutional 
condition. The interstitial form generally reacts to antisyphilitic treatment. 
Children poorly nourished or badly housed must be removed to hygienic quarters 
to effect a cure. Good food, fresh air, and baths add greatly to the possibilities 
of local treatment. Any fissures in the angles should be treated with silver 
nitrate solution (dram one to the ounce), followed by a flushing with normal 
saline. 

Placing a shade over the eyes is preferable to a darkened room for the child. 
Bathing with hot boric acid solution three or four times a day is soothing and 
helpful. An ointment of yellow oxid of mercury (1/100) may be supplied for 
use on the eyelids at night in phlyctenular keratitis, and an ointment of bichlorid 
of mercury (1/5000) applied for the other varieties. A solution of atropin sul- 
phate {\ per cent.) may be necessary in some cases to give rest until the child 
responds to the general treatment. 

The Diagnostic Significance of Ocular Affections. 

The eye may so often be of assistance in establishing a diagnosis that 
a short article will be devoted to the interpretation of certain ocular lesions 
or manifestations. 

Every physician should be prepared to make certain simple tests in 
his office to discover ocular defects, and the eyes should be examined in the 
routine examination, even when the patient is not presented for defective 
eye-sight. In this way he may find the cause for backwardness in school 
studies, headache, and dizziness. Of still greater importance is the fact 



THE COMMONER DISEASES OF THE EYE. 539 

that recognizing unsuspected deficiencies in visual acuity he will refer the 
child to an oculist for more rigid and detailed tests and correction of 
refractive errors while the eve is still in the formative period. All that is 
required for these tests is a Snellen's test card, a graduated picture card for 
children unable to read, a candle placed at twenty feet and the multiple 
rod of Maddox for testing the functional balance of the ocular muscles. 

Talk has shown that the x4mericans as a nation are found to be far- 
sighted with astigmatism. There is no doubt that many of the children 
of this generation suffer from overuse of their eyes because of the compe- 
tition of school life and the multiplicity and cheapness of all forms of 
reading matter to which they have unrestrained access. 

Parents must be warned of these conditions and prophylactic measures 
advised to protect the vision of their children so that artificial aid may not 
be required. The study room should be well-lighted and ventilated, with 
the desk or table so placed that the light will come over the left shoulder. 
The u>e of vertical writing is to be commended. Reading in the recumbent 
position or during convalescence should be prohibited. Badly printed books 
should not be tolerated in these days of modern printing. 



Diagnostic Hints. 

Ptosis as seen in children is usually a congenital defect as lesions of 
the oculomotor nerve are exceedingly uncommon in childhood. 

Photophobia is not uncommon and usually indicates some inflamma- 
tory affection of the structures of the eye, for example, corneal ulceration. 
It does not usually occur with conjunctival diseases. 

Exophthalmos, or prominence of the eye-ball, is sometimes seen in 
older children who have the symptoms of goiter. 

Diplopia indicates paralysis of any of the straight ocular muscles, and 
it may result from any cause which will prevent both eyes being fixed on 
the same point. The form varies with the muscle affected. It is sometimes 
a symptom in hereditary ataxia. 

Strabismus appearing suddenly, convergent in character and accom- 
panied with diplopia, is one of the signs of tuberculous or basilar meningitis. 
It may also be seen in hysteria, but here is functional only in character. 

Nystagmus, or rapid oscillation of the eye-balls, may be lateral, ver- 
tical, or rotary movements. It usually is bilateral. It occurs rarely ron- 
genitally, and is then without serious significance. It is observed in many 



540 DISEASES OF CHILDEEN. 

cerebral diseases, especially those associated with congenital defects, in dis- 
seminated sclerosis, and in Friedriclr's ataxia. Tnmors of the cerebellum 
or pons may produce this ocular symptom. It is sometimes seen in the 
later stages of hydrocephalus. 

Optic Neuritis (Choked Disk), Papallitis. — This condition may be 
found on ophthalmoscopic examination and indicates some form of intra- 
cranial lesion or affection of the orbit. Papillitis is seen in meningitis, 
particularly of the tuberculous variety; sometimes it occurs with tumor 
and abscess of the brain. 



SECTION XVII. 
DISEASES OF THE SKIN. 



CHAPTEE XLII. 

DISEASES OF THE SKIN. 

Introduction. 

Diseases of the skin form a very important part of the affections of 
early life. In infants this is particularly true, owing to the hypersensitive- 
ness of the skin, which is suddenly bereft of its covering of vernix caseosa 
at birth and exposed to irritants of varying degree either from without or 
from within. It must also be recollected that faulty metabolism will ac- 
count for many of these skin lesions. Young protoplasm is very irritable, 
and hence comparatively slight causes may produce severe lesions of the skin. 

The causative factor should be carefulty sought after in each case, and 
treatment should be directed not alone to the local lesion, but to the systemic 
condition as well. AYhen prescribing local treatment the tenderness and 
sensitiveness of the infantile epidermis should not be forgotten. Better and 
more permanent results are obtained if soothing and unirritating drugs are 
employed and if the skin is protected from further injury by prevention of 
scratching or further infection. The latter condition often masks the 
nature of the original disease, hence the most recent lesion must always be 
sought for diagnostic purposes. 

A certain number of skin diseases are congenital or are seen mainly in 
infancy. These will be mentioned first and then the commoner diseases 
met with in the early years of life, and finally those seen for the most part 
in the school age. 

Ichthyosis. 

(Xerodermia.) 
Ichthyosis, or fish-scale disease, is regarded as a congenital skin affec- 
tion, mainly transmitted by heredity. It is characterized by a dry scaling 
condition of the skin, whose outer layers are hard, dry, and thickened and 
without any inflammatory phenomena. Several members of a family may 
be affected. 

Symptomatology. — The whole body, as a rule, may be covered with a 
scaling, wrinkled, papery skin, especially on the outer surfaces of the arms 

541 



54:2 



DISEASES OE CHILDBED. 



and legs. In the flexures of the joints fissures are sometimes formed. The 
general health remains unaffected. Irritants easily cause pruritis and local 
inflammatory reaction. 

Diagnosis. — The disease is rarely mistaken on account of its distinct 
characteristics. The history and its non-inflammatory character distinguish 
it from trophoneuroses or pityriasis. 

Prognosis. — It is an intractable disease requiring long and patient 
treatment to affect any amelioration. It is never really cured. 




Fig. 170. — Pigmented nevus. 

Treatment. — ■ If the treatment is begun in early infancy much more 
can be accomplished than when seen later. Baths of green soap, followed 
by inunctions of lanolin or vaselin and protection of this greased surface 
with gutta percha tissue, later a 5 to 10 per cent, sulphur ointment, can be 
applied. Life in the tropical countries is favorable to comfort and possible 
cure. 



Nevi. 

These congenital growths may be vascular or pigmented (moles). The 
latter may also be hairy or rough and warty. The color varies from a light 
brown to black. Vascular nevi are due to local excessive proliferation of 
blood-vessels at or soon after birth. These disfigurements are found for the 
greater part in the corium, and vary from the familiar port-wine stain to 



DISEASES OE THE SKIX. 543 

pulsating angiomata. They are apt to increase in size soon after birth and 
do not grow beyond certain limits. 

Prognosis. — Vascular nevi of the cavernous type may be dangerous 
to life because of the danger of bleeding or from their effect on neighboring 
structures. Pigmentary nevi have shown metamorphic changes into later 
growths of a malignant character. 

Treatment. — This is accomplished by electrolysis or cauterization act- 
ing upon the corium only. Eadiotherapy occasionally is successful. Ex- 
cision offers the best results ; occasionally skin grafting is necessary follow- 
ing excision of a large nevus. A needle may be heated to a cherry-red color 
and plunged into the margin at three or four points. This may be repeated 
at subsequent sittings until the nevus has been entirely eradicated. A white 
scar remains over the site. Ice made from liquid carbon dioxid is often 
suitable for the removal of port-wine stains or superficial nevi. 

Dermatitis Exfoliativa Neonatorum. 
(Ritter's Disease.) 

Badly nourished infants, usually nurslings, are affected by this disease. It 
is quite rare. It begins, as a rule, on the lower half of the face as a reddened 
area with exfoliation. This erythema soon spreads over the entire body, and 
the resulting scaling is profuse. Fissures appear at the mouth and anus. Com 
stitutional symptoms are those of malassimilation or. in severe cases, those of 
sepsis. Even when restitution to the normal takes place after patient and dili- 
gent treatment, relapses are not uncommon. Ritter gives the cause as a general 
sepsis. 

Course and Prognosis. — The two cases coming under our observation in 
hospital practice were markedly toxic, and both died. The mortality is 50 per 
cent. Occurring as they do among the poorer classes, medical attention is not 
drawn to them until the vitality has suffered beyond repair. 

Treatment. — Maintain the body heat by the use of lanolin and such manage- 
ment as is recommended for the premature (see p. 2). Carefully examine the 
breast milk, and if abnormal a wet-nurse is indicated. Strychnin in doses of 
gr. 1/300 every two or three hours is given if the vitality is low. 

Pemphigus Neonatorum. 
Tins is a contagious skin disease characterized by the formation of 
bulla? containing a purulent fluid. Xo specific microorganism has as yet 
been isolated. The large vesicles or bulla? may sudlenly make their appear- 
ance on any part of the body, causing little or no systemic disturbance. 
The blebs vary from transparent to grayish forms. The distended vesicles 
may rupture, leaving a crust and a reddened base, but no scar formation 
results. The exudate may infect new areas or even tbose in contact. Tbe 
disease usually runs a favorable course, tending to complete recovery in a 
few weeks. Tbey should be differentiated from the bullous syphiloderm, 
sometimes called syphilitic pemphigus, which occurs mainly on the soles of 



o-i-i 



DISEASES OF CHILDBED. 



the feet and palms of the hands, with usually an ulcerated base, and is 
accompanied with other manifestations of infantile syphilis. 

Treatment. — Evacuate each bleb carefully by pricking with a sterile 
needle, and apply zinc stearate for desiccation. A daily bath in a solution 
of bichlorid of mercury (1/10,000) is indicated if self -inoculation is 
evidently going on. 

Impetigo Contagiosa. 

This skin disease usually attacks 
the face at the corners of the mouth 
and nostrils, although any portion of 
the body may exhibit the lesions. These 
consist of grayish-yellow sticky crusts 
which have a honey-like discharge. 
They are seated upon a red base. The 
child eagerly picks at these crusts and 
infects other areas. 

Treatment. — The general health, 
if deficient, will require proper feeding 
with iron or cod-liver oil. The crusts 
are softened by green-soap poultices and 
removed. The areas are then covered 
with benzoated lard or lanolin with bi- 
chlorid of mercury gr. i to the ounce. 

Seborrhea Capitis. 

Overactive sebaceous glands pro- 

kduce a crust of sebum which soon be- 
. I comes dry and scaly. It commonly 

occurs upon the scalp and forehead 

It is a dirty 
yellow, firmly adherent mass lying upon an uninflamed surface. It is more 
commonly found in poorly nourished children than in lusty breast-fed babies. 
Treatment.— Attention must be given to the general nutritional re- 
quirements, together with local applications of warm olive oil or boric acid 
ointment (10 per cent.) under an oil-silk cap. Applications of the oint- 
ment are made twice a day, until finally the crust has softened. They are 
then removed with a superfatted soap or a glycerin soap and the scalp 
anointed daily for a time with a 2 per cent, sulphur ointment. 




Fig. 171.— Impetigo 
in infants, and is known by the laity as "milk crust/ 



DISEASES OF THE SKIN. 545 

Erythema Multiforme. 

This is an acute inflammatory disease, in which are variously produced areas 
of erythema, macules, papules, or vesicles. Some constitutional disturbance may 
usher in the attack. This is usually mild in character; there may be fever and 
malaise with or without rheumatic pains. The lesions, as a rule, appear on the 
extensor surfaces of the hands, arms, feet, and legs. The face and upper chest 
are often involved, although any part of the body may exhibit the eruption. 
The color varies from a light red at first to a deep red in older lesions. Only 
occasionally are hemorrhagic areas seen. Pruritus is not a marked symptom. 
Accompanying the erythema in children there are usually observed symptoms of 
intestinal derangement, autointoxication, ptomain poisoning, etc., which have 
undoubtedly produced this external manifestation. The disease is liable to recur- 
rence, lasting, as a rule, for a few weeks before subsiding. 

Treatment. — This should be mainly directed to the underlying viceral 
derangement. An initial purge is indicated in the form of calomel or castor oil. 
A careful history of the child's diet will nearly always disclose some radical fault 
which needs correction. A specially arranged dietary should be provided. The 
emunctories should be kept active. Locally, if there is pruritus, an ointment 
containing resorcin or acid carbolic may be applied. 

Acute Exfoliative Dermatitis. 

This condition is of interest because of the confusion which it may cause in 
children from its resemblance to scarlatinal infection. 

Intestinal toxemia will commonly be found to be the underlying cause. 
Following an erythema of the scarlatiniform type, in a few days or sometimes 
hours, there occurs a profuse exfoliation. Constitutional symptoms are more 
pronounced than in scarlatinal erythema. The exfoliated scales of large and 
papery strips are cast off (see Fig. 8, Plate IX). The hair and nails may drop 
out before the process is complete. Furnuncles and pustules are sometimes 
engrafted on the dermatitis with involvement of the neighboring lymphatic 
glands. 

Diagnosis. — The differential diagnosis in the erythematous stage and in 
that of exfoliation is given under the article on Scarlet Fever (see page 22-1). 

Treatment. — Correct the toxemia by unloading the intestine and prescribing 
a diet that will not cause fermentation. Repeated examinations of the urine for 
indican will assist in properly meeting this indication. Fowler's solution with 
iron is of value after the dietetic error has been corrected. A 2 to 5 per cent, 
ichthyol ointment is soothing to the skin. The cure is slow and recurrences are 
frequent. The exfoliation may occur two or three times a year. 

Eczema. 

(Tetter; Salt-rheum.) 

This is a protean disease of unknown origin assuming an acute, sub- 
acute, or chronic course, characterized by an erythematous eruption of vary- 
ing intensity, which goes on to scaling or crusting and is associated 
invariably with marked pruritus. 

It is the most common of all the skin diseases observed in early life. 

Etiological Factors. — Irritants either of external or internal origin, 
or both, are responsible for the affection. Children who have the spasmo- 
philic tendency, nutritional or blood disorders, are particularly susceptible. 
The usual pyogenic bacteria found on the skin are no doubt responsible 
indirectly for many cases. Their growth is facilitated or incroa«'<! by 
35 



546 



DISEASES OE CHILDREN. 



mechanical or chemical irritants with which the child comes into contact. 
The so-called " predisposition " to the disease is often accounted for by 
careful investigation for the cause along the lines above enumerated. Para- 
sitic skin diseases, discharges from various parts of the body, badly prepared 
soaps and powders, and irritating underclothing are among the more com- 
mon external causes. Excessive feeding, in general or in kind, but par- 
ticularly the sugars, and constipation, are the prominent internal causes. 

Varieties. — Depending upon the degree 
of the exudative inflammation in the epithe- 
lium, there is produced an erythematous, 
papular, vesicular, or pustular eczema. 

These forms either remain distinct or 
merge one into the other, somewhat masking 
the original type. The erythematous va- 
riety is characterized by redness and swelling 
over certain areas, especially the face. The 
papular type is known by the formation of 
small red papules which tend to group and 
coalesce. In the vesicular phase the upper 
layers of the epidermis are raised by the 
exudative process, forming vesicles or blebs 
which tend to coalesce and exude a viscid 
serum. These, however, are evanescent and 
are rarely seen because they are rapidly dis- 
solved off, leaving a wet surface. If the lat- 
ter form becomes infected by pyogenic skin 
bacteria or overloaded with leukocytes the 
pustular form develops. 

Sub-varieties. — When the discharge in 
the vesicular form dries readily it forms 
crusts (E. crustosum). If the exudation is 
profuse and the rete is uncovered, the weep- 
ing or moist form results (E. madinans vel rubrum). A squamous variety 
is superimposed or develops from the crusty, papular, or vesicular form 
when considerable epidermal infiltration and scaling appears. 

Chronic Varieties. — These result from repeated recurrences, or ex- 
acerbations, or neglect of the etiological factors. The chief characteristic 
is the infiltration into the upper layer of the skin. 

Symptomatology and Diagnosis.— All the varieties described above 
have certain common features, namely, redness, itching, and burning, accom- 
panied by the formation of papules, vesicles, or pustules, the skin being 




Fig. 172. — Chronic eczema. 



DISEASES OE TELE SKIN. 



547 



either dry, moist, infiltrated, or scaling. In infants the scalp, face, and 
napkin region are most frequently attacked. The diagnosis is, as a rule, 
not difficult if the above description and classification is kept in mind. 
Erysipelas is distinguished by the rapidly spreading margin and high fever. 
Scabies is often confounded with eczema or the two are combined. The 
distribution and the itching, which is worse at night, the history of the 
other children or members of the family similarly affected, or the burrows 
and their contents themselves, can be depended upon to establish the diag- 
nosis. Psoriasis is rare in early life; it is never moist; it is commonly 




Fig. 173. — Child with eczema fitted with metallic glove to prevent scratching. 



found upon the elbows and knees, and has silvery scales. Syphilides occa- 
sionally are difficult to distinguish. The infiltration is deeper and greater; 
they do not burn or itch and are usually accompanied by other manifesta- 
tions. In difficult cases the Wassermann test may be emplo)'ed. Impetigo 
contagiosa has discrete vesicles upon a slightly reddened skin, with abrupt 
margins. They are contagious and the child easily inoculates itself in 
different parts of the body. 

Prognosis. — This is variable, depending upon the underlying cause 
and the time of instituting treatment. Acute cases are favorable, but the 



548 



DISEASES OF CHILDREN. 



chronic varieties are often intractable and persist with exacerbations and 
recurrences for years. 

Acute Eczema. — Treatment. General. — The underlying cause 
should be carefully sought for and removed. If this is accomplished the 
cure will be well under way. Especially important is the proper regulation 
of the diet. If there is present such a condition as rickets, marasmus, or 
anemia the diet must be so arranged as to overcome the nutritional disorder. 
Cod-liver oil is often helpful. If, on the other hand, there has been over- 
feeding or indulgence in special articles, 
as the sugars or potatoes, such indiscre- 
tion must be stopped. The constipation 
should be relieved by correcting the 
diet or adding thereto such articles as 
fruits, the drinking of plenty of water 
and appropriate massage and exercise. 
In infants the milk of magnesia may 
be added to the milk for its laxative 
effect. 

Local. — Never allow soap or water 
to be used on any eczematous surface. 
Cleansing can be satisfactorily accom- 
plished with olive or linseed oil. The 
irritated skin must be treated by bland, 
soothing ointments or powders and scratch- 
ing absolutely prevented. Eest for the 
inflamed area is imperative. Scratching 
is prevented by the use of masks, band- 
ages, or sleeves, as shown in the illustra- 
tion (Fig. 174). 

The mild cases of the erythema- 
tous, papular or moist types may be 
dusted with stearate of zinc, carbonate of magnesia, oxid of zinc, or boric 
acid. 

In the inflammatory stages lotions of 2 per cent, boric acid, calamin, 
or a 1 per cent, solution of aluminum acetate, are applied as moist dressings. 
These soothe and reduce the inflammation. Occasionally small areas of 
weeping eczema may be rapidly improved by the primary application of 
■J per cent, solution of the nitrate of silver. Among the ointments, Lassar's 
paste (X. F.) has given us the best results. It is applied thickly over the 
inflamed area and a retaining bandage or mask is applied. If thick crusts 




Fig. 174. — Eczema mask with stiff 
sleeves to prevent scratching 



DISEASES OF THE SKIN. 549 

are present these must first be removed with applications of olive oil or boric 
acid ointment. The dressings are removed daily, the ointment carefully 
removed with absorbent cotton dipped in oil and the ointment reapplied. 

Subacute Eczema. — If for any reason treatment has been delayed or 
has been unsuccessful in the acute stage more stimulating applications are 
necessary. The amount of oxid of zinc in the pasta Lassar (N. F.) may 
be increased, and small amounts of tar in the form of tincture picis liquidae 
may be added, or the following may be used : 

R Picis liquidae 3ss 

Sulpburis praecipitati 3j 

Dnguenti zinci oxidi . ^lj 

Misce et signa. — Apply morning and evening. 

The same precautions must be observed to prevent scratching or irrita- 
tion of the area, and the diet and bowels regulated. 

Chronic Eczema. — Perseverance and careful watchfulness as to the 
action of the drugs used in this form will be necessary to effect a cure. 
The thick crusts must first be removed by applications of oil, boric or bis- 
muth ointment. Stimulating ointments are then to be used. The majority 
of children bear the ointments well, but occasionally they are not well tol- 
erated and stimulating lotions must be substituted. Tar is added in greater 
proportion to the ointments which have been recommended above. The 
tincture picis liquids or the liquor carbonis detergens act advantageously by 
producing stimulation and at the same time preventing itching. If large 
areas are affected, it is well to apply the tar ointment to limited portions of 
the skin first and observe its effect. After it has produced an acute reaction 
the milder pastes are applied. 

Psoriasis. 

Psoriasis among the skin affections is quite commonly observed in 
apparently healthy children. It begins as a papular affection with silvery 
scales on their summits. Their growth causes the commonly observed ir- 
regular patches with well-defined edges, of a bluish-red color, somewhat 
raised above the surrounding skin. Invariably silvery scales are found in 
these plaques, which can be readily removed, leaving a reddish glazed base. 
The extensor surfaces of the extremities are the favorite seats, next the 
trunk and scalp. The affection is a chronic one, with a great tendency to 
return in spite of well-directed treatment. Spontaneous cure in the summer 
months is not uncommon. 

Treatment. — Bulkley emphasizes the dietetic treatment, and as the 
youthful patient is apt to be indiscreet, this should be the first consideration. 
A vegetarian diet may be appropriate for the child with a rheumatic history, 
although obviously unfitted for an anemic child below weight. Outdoor 



550 DISEASES OF CHILDREN". 

life at the seashore, with sea-bathing, is productive of much good. As soon 
as the lesion appears an application of green soap and a full bath are ordered 
to remove the superficial scales. A crysarobin ointment is applied to a small 
area in the strength of 5 to 10 grains to the ounce (except to the face) 
twice a day until the skin is clean. Latterly X-ray treatment has produced 
rapid results. Warning should always be given as to its liability to return 
and the importance of renewing the treatment early. 

Miliaria. 

(Prickly Heat; Strophulus.) 

Miliaria is an affection developing at the sudariporous glands, usually 
during the summer months. It consists of numberless minute reddish 
papules and vesicles which appear with or after an unusual amount of per- 
spiration. It is accompanied by itching and burning. After a few days 
to a week it subsides, although fresh outbreaks are likely if weather con- 
ditions are favorable. Evidences of scratching are often seen in children 
in connection with miliaria. 

Treatment. — A 4 per cent, solution of boric acid is soothing, or with 
infants bran baths may be used. Frequent bathing and light clothing are 
prophylactic measures with children in the summer months. Eemoval to 
the seashore and sea-bathing produce rapid amelioration and cure. 

Urticaria. 

(Nettle-rash; Hives.) 

Urticaria consists of large wheals made up of a localized area of edema 
in the papillary layer of the skin. Their centers are pale, while the margins 
are reddened. These wheals are distinctly felt by the hand and cause in- 
tense itching, especially at night. In the majority of cases urticaria results 
reflexly from intestinal causes. External irritants, such as the stinging 
nettle (hence one of its names), insect bites, etc., may bring on a typical 
attack. Certain fruits, as strawberries, produce urticaria in the predis- 
posed. A small papular urticaria, consisting of minute papules, the tops of 
which are soon scratched off, causing a drop of serum or blood to exude, 
may often be seen in early life. This form may persist for months and, if 
neglected, will eventually result in a form of papular eczema. This variety 
is in all cases the result of a prolonged faulty diet. Strophulus is a name 
sometimes given to this condition. 

Treatment. — Discover the offending cause, whether external or die- 
tary. Locally, baths containing bicarbonate of soda, salines for the bowels, 
and local applications of ointments containing menthol, camphor, or carbolic 



DISEASES OF THE SKIN. 551 

acid. Small doses of salicylate of sodium or aspirin will relieve the intes- 
tinal fermentation that is often the underlying cause of urticaria. 

Furunculosis. 

This is a condition in which boils occur over an}' part of the body, but 
especially about the head. They are due to an infection of the skin with 
pyogenic organisms. The staphylococcus pyogenes aureus is the predomi- 
nating direct cause. They differ in their virulency and occasionally cause 
marked systemic infection. Lowered vitality from malnutrition, improper 
feeding, previous debilitating diseases, and skin diseases predispose to the 
formation of furuncles. 

They are usually small in size, multiple, and tend to rapid formation 
of pus. If uncared for, they rupture and the pus may inoculate other 
abraded surfaces. The areas are painful to the touch, reddish or bluish-red, 
and discharge a yellowish, creamy pus. Children with furuncles are rest- 
less, sleep badly, may have a low-grade temperature, cry inordinately, and 
lose flesh and strength. 

Treatment. Local. — A general bath in bichlorid of mercury 
(1/5000) is first ordered; the furuncles in which suppuration has occurred 
are then surrounded with lanolin, incised and drained completely, exercising 
care not to infect neighboring regions with the pus. Eemove local causes, 
if any, as scabies. 

General. — Improve by diet and fresh air the general tone, prescribing 
strychnia, nux vomica, or the bitter wine of iron in the anemic. The re- 
sistance may be raised by the injection of vaccines in cases in which recur- 
rences are common or in which the systemic infection is marked. 

Herpes Zoster. 

{The Shingles; Zoster.) 

Herpes zoster is a painful acute inflammatory affection characterized 
by the production of a vesicular eruption appearing over the course of dis- 
tribution of the cutaneous nerves. It is accompanied by an inflammation 
of the peripheral nerves or of the sensory ganglia of the posterior nerve roots. 

Following a day or two of localized pain, there will appear on one side 
of the body a crop of vesicles having a reddened inflamed base, which are 
seen to follow the distribution of an affected nerve. The vesicles, as a rule, 
dry up without pustulation, unless infected by unclean children. Adults 
suffer more intensely with this affection than do children. It is recognized 
by its unilateral distribution over a nerve tract emphasized by the symptom 
of pain. 



552 



DISEASES OF CHILDEEN. 



Treatment. — Locally, stearate of zinc as a dusting powder and a pro- 
tective dressing are required. Small doses of phenacetin or codein may be 
required for the relief of pain. The incandescent lamp has given relief in 
some cases, as have the X-rays. 




Fig. 175. — Herpes Zoster. ( Walker. ) 



Pellagra. 

Since the investigations by the Pellagra Commission cases of this disease 
have been found among the children, especially in our Southern States. 
The disease manifests itself in disorders of the digestive system, localized 
erythemata of the skin, and varied nervous symptoms. Its etiology is still 
obscure. It occurs chiefly among those living in unhygienic quarters, and 
who are likely to subsist upon damaged corn. 

Symptoms. — The acute manifestations appear as undefined attacks of 
gastro-enteritis, accompanied by extreme lassitude and weakness. After a 
variable time skin lesions appear, for the most part upon the extensor sur- 



DISEASES OF THE SKIN. 553 

faces of the arm and hand, and on the back of the face, neck and feet. The 
skin is mottled red, with a formation of blebs, which tend to become indu- 
rated and desiccated. These lesions are symmetrical. Except for restless- 
ness and insomnia, further neurotic symptoms are not apt to manifest 
themselves in children. 

Treatment. — Bemoval to a northern climate, improvement of hygienic 
conditions, plain nourishing food, with arsenic and iron, are indicated. 



CHAPTER XLIIL 

PARASITIC SKIN DISEASES. 

Children are more liable to this group of diseases because of their 
vulnerable, tender skin, and because even clean children are apt to mingle 
with their uncared-for schoolmates. 

Pediculosis. 

These are insects readily seen under a low-power glass. The head 
louse is from 1 to 2 mm. in length, has a head, thorax and abdomen, and a 
sharp proboscis by which it attaches itself. They are extremely prolific, the 
female laying about fifty eggs, and the young being ready to multiply their 
kind after three weeks of life. The ova are enveloped 
in a capsule and are attached to the hair. These are 
commonly known as nits. The parasite feeds by im- 
bedding its proboscis in the scalp and 

sucking. Thus the intense itching is 

caused. Scratching causes further 

irritation and patches of eczema may 

appear. The post-cervical glands are 

enlarged in neglected cases, and a red 

line at the base of the hair behind is 
Fig. 17b'— Pedicu- °^ en visible to confirm the diagnosis, 
lus capitis. Micro- The nits are distinguishable from 

tnoema^r.) After dandruff soales ^ their P osition on 
the hair, their tenacity to it, and the 

ability to move them up and down the hair. 

Treatment. — Cut the hair as closely as possible in long-standing cases 

if no great objection is made. Apply a cap made of a light towel soaked 

in coal-oil (kerosene) or pour alcohol over the scalp, beginning at the base 

with the head held over a basin; the parasites will then move on before it 

and are washed away. In the daytime a 10 per cent, boric ointment is 

rubbed into the scalp in aggravated cases to allay the irritation. The nits 

are removed only after patient treatment with a fine comb. 

Scabies. 

{The Itch.) 

Scabies is a disease of the skin produced by the Sarcoptes scabiei or 
itch-mite, which by its entrance into the skin produces burrows and an 

554 





Fig. 177.— Nits 
of pediculus capitis. 
{After Anderson.) 



PAKASITIC SKIN DISEASES. 555 

eruption of vesicles, pustules, and nodules. To these are added the scratch- 
marks produced by the patient's finger-nails. Infants and young children 
are greatly annoyed by the irritation and the evidences of scratching are 
observed early. The inter digital spaces, the wrists and flexor surfaces of 
the forearms, the toes and inner surfaces of the thighs are especially 
affected. The whole body may be invaded in unrecognized or neglected 
cases. The prominent symptom, itching, is worse when the patient is in 
a warm bed. If the child is predisposed to eczema this is almost sure to 
supervene, and, in fact, sometimes masks the original cause. The disease 
is commonly seen in dispensary children, who are 
apt to sleep with others and receive meager bodily 
attention. 

The itch-mite can with care be seen by the 
naked eye. The female is larger than the male. 
They are ovoid in shape, covered with hairs and 
have a pair of mandibles by which they attach 
themselves to the skin in burrowing. The female 
deposits its eggs and perishes, while the colony 
work their way to the outer skin and start burrows 

of their own. 

-, mu n- j-i 1.1 FlG - 178.— The itch-mite. 

Treatment. — Ihe disease is readily amenable (Neumann.) 

to cure if certain rules are followed faithfully. 

Remove all the clothing and bedclothes and sterilize them by boiling or 

baking in an oven. Follow a vigorous soap and hot-water bath with the 

application of sulphur ointment drachm one to the ounce. If eczema is 

present, use mild detergents, especially in the case of infants. Powdered 

sulphur may be used in children or a solution of styrax in the strength of 

half an ounce to the ounce of lanolin. The ointment selected should be 

applied to the whole body twice a day and two weekly baths taken. If there 

is a superadded eczema, treat the latter along the lines outlined for that 

disease. 

Tinea Tonsurans. 

{Ringworm of the Scalp.) 

This is a contagious disease produced by a vegetable parasite, beginning 
as a mass of minute vesicles which soon affect the hair. 

The lesion consists of a rounded patch showing broken-off hairs 
(shaven beard appearance) or a partly bald area, with extension taking 
place into the periphery. The central area is more or less reddened with a 
dirty scaly margin. 




556 



DISEASES OF CHILDREN 



The disease is almost entirely confined to children, rarely appearing 
after puberty; children infect each other directly or through articles of 
clothing or toys or through their pets. The patches are rarely seen by the 
physician while vesicles are present. 

The diagnosis must be made on the presence of the gnawed-off looking 
hairs in a rounded, reddened, scaly field in which the fungus can be found 
on the hairs. 

Examination for the Fungus. — A loosened diseased hair may be 
placed on a slide and soaked in a 10 to 20 per cent, potash solution, and 
examined for the parasite under the microscope with at least a J-inch lens. 




Fig. 179.— Favus of the scalp. (Walker.) 



Treatment. — Eingworm does not respond quickly to treatment. If 
depilation is first performed, a better response to antiparasitic remedies is 
obtained. The scalp should be cleansed for several days with green soap 
and water. The surrounding hair is best kept short or, if possible, shaven 
about the lesion. A solution of potash applied on a piece of gauze and 
rubbed in will remove any debris that remains after the washings. An 
antiparasitic ointment is now daily applied and a protective dressing or cap 
used. We have tried to our satisfaction applications of oil of cade and 
castor oil, equal parts, or betanaphthol one-half to one drachm to the ounce. 
Ten per cent, aristol in flexible collodion has commended itself in children 
who are in asylums and apt to infect others. The X-rays are highly spoken 
of by dermatologists as a rapid and permanent means of cure. 



PARASITIC SKIN DISEASES. 557 



Tinea Favosa. 



Favus is a feebly contagious parasitic disease, caused by the Achorion 
Schonleinii. The lesion consists of sulphur-yellow areas on the scalp through 
which the hairs appear. The hair shaft is broken off, being diseased by the 
fungus. Closely examined, it is found that each hair is surrounded by a cup- 
shaped area : tbese coalescing produce a thick matted cake, dirty yellow in color, 
sometimes having a peculiar characteristic odor. Some pruritus is nearly always 
complained of. When the crusts are removed a scarred area with no hairs 
present is found. The diagnosis may be confirmed by an examination for the 
fungus under the microscope. A low power will answer (250 diameters). A 
fragment of hair passed through a potash solution will show the thick broad 
threads. The spores seen are of many shapes and sizes. 

Treatment. — The treatment takes much time and patience, and at best, 
bald areas will occur at times. Depilation offers the safest and best chance of 
cure. This is performed after cutting short all the hair of the head, removing 
thoroughly all the crusts and debris with 10 per cent, boric acid ointment. The 
hairs are removed best with Bulkley's adhesive, made up with burgundy pitch or 
by repeated collodin applications. The hairs are thus removed en masse. Ten 
per cent, oleate of mercury is then applied night and morning with frequent soap 
and hot-water washings. When new hairs appear the microscope should again 
be used to guard against the reappearance of the parasite. The X-ray may here 
also give good results in competent hands. 

Alopecia Areata. 

(Baldness.) 

This is a disease of the hairy scalp producing areas of baldness. The affec- 
tion is apt to come on quite suddenly without any subjective symptoms. The 
underlying skin is white, clean, and soft. When the hair returns, which it does 
in children, it is soft, downy, and colorless at first. Later it slowly shows some 
color and the hairs themselves become firmer and of coarser texture. Schamberg 
believes there are two varieties : the parasitic and the trophoneurotic, thus 
explaining the divergence of opinion as to the etiology. 

After a variable time, sometimes months, the hair in children returns, 
although even in early life relapses are seen. 

Treatment. — Locally — many remedies have been advanced as serviceable. 
Measures which will increase the blood-supply in the scalp are helpful. Vigorous 
massage, followed by applications of 90 per cent, alcohol, has been useful in our 
hands. Lately the high-frequency current and the actinic rays have been 
extolled in the cure by dermatologists. 



Ivy Poisoning. 

The poisonous action of Rhus toxicodendron and other varieties of rhus (as 
the poison sumach) is not infrequent anions children who are susceptible. City 
children, because of their unfamiliarity with the plant, are more apt to expose 
themselves to its venomous activity. When barefooted they are particularly 
liable to come in contact with it. and they readily spread the poison to their face. 
neck and genitals. The erythematous eruption appears within a few hours, and 
is followed by numerous vesicles which soon rupture and wet tbe surface with 
their serous exudation. Signs of inflammation, pain, bent and swelling are still 
further aggravated by intense itching. About tbe face tbe edema may produce 
great disfigurement; after reaching its height the erythema subsides in a few 
days, especially if restitution to tbe normal is assisted by appropriate treatment. 
Children and their parents should be taught to recognize these plants and know 
their characteristics. 



558 DISEASES OF CHILDREN. 

Treatment. — The child should be restrained from infecting other parts of 
the body and from scratching the acutely inflamed area. If the eruption is seen 
soon after its appearance the parts should be copiously bathed with an alkaline 
solution, such as a 5 per cent, solution of bicarbonate of soda. Then apply gauze 
wet with a 2 per cent, solution of permanganate of potash. The physician, if 
susceptible himself, should wear rubber gloves when doing the dressing. The 
dressing should be applied in such a way as to prevent the ruptured vesicles from 
coming in contact with the healthy skin. After the acute stage is passed, soothing 
ointments such as Lassar's paste produce good results. 



INDEX 



Abdomen, as aid to diagnosis, 89 

enlarged, 89 

prominent, S9 

tumors of, localized, 89 
Abdominal wall, tumors of, 90 
Abnormalities in breathing, as aid to 

diagnosis, 87 
Abscess, cerebral, 490 

ischiorectal, 526 

of brain, 490 

of liver, 213 

of lung, 361 

peritonsillar, 338 

pulmonary, 361 

retropharyngeal, 338 

subphrenic, 363 
Absence of bones, congenital, 508, 510 
Acetonuria, 432 
Achondroplasia. 404 

diagnosticated from cretinism, 408 
Acne, vaccine therapy in, 82 
Addison's disease, 400 
Adenie, 400 
Adenitis, acute, 401 

chronic, 402 

tuberculous, 304 

vaccine therapy in, 81 
Adenoids, 335 

etiology, 335 

examination, 337 

symptomatology, 335, 336 

treatment 337, 338 
Administration of drugs, 63 

of food for infants, 152 
Adolescence, 36 
Adrenals, disorders of, 400 

hemorrhage into, 400 
Aerotherapy. 69, 70 
Air. fresh, 69 
Albuminuria, cyclic, 431 

functional, 431 

physiologic, 431 
Alcohol sponge bath, 72 
Alopecia areata, 557 
Amaurotic family idiocy, 501 
Amebic dysentery. 100 
Amygdalitis, acute. 331 
Amyloid liver. 212 
Anamnesis of sick child, 39 



Anemia, 383 

pernicious, 385, 388 

secondary, 383 

simple, 383 

splenic, 388 

von Jacksch's, 386 
Anemias, table of, 388 

treatment of, 390 
Anesthesia, 516 

chloroform, 516 

gas-ether, 517 

preparation for, 517 
Anesthetic, choice of, 516 
Angina, streptococcic, 333 

Vincent's, 333 
Angioneurotic edema, 473 
Animal parasites, 201 

lound in childhood, 201 
Ankylostomum duodenale, 206 
Anopheles mosquito, 294 
Anterior poliomyelitis, 282 
Antitoxin, diphtheria, 244, 245 
Anuria, 429 
Anus, fissure of, 526 

imperforate, 507 

malformations of, 507 

prolapse of, 527 

stenosis of, 507 
Aortic obstruction, 375 

regurgitation, 375 
Aphtha?, 171 

Bednar's, 171 
Apoplexy, meningeal, during birth, 8 
Appendicitis, 519 

abscess formation, 521 

diagnosis, 521 

etiology, 519 

examii ation, 520 

pathology, 519 

prognosis. 521 

suppurative form, 520 

symptomatology, 510 

treatment. 521 
Appendix, of infant. 31 
Arthritides, infectious, 203 
Arthritis, diagnosed from rheumatism, 
200 

tuberculous, 204 
Arthritis deformans, 203 
Arthrogryposis, 460. and see Tetany 



559 



560 



INDEX. 



Artificial respiration, 10 
Articular rheumatism, acute, 288 
Ascaris lumbricoides, 202 
Ascites, 525 

chylous, 526 
Asphyxia, during birth, 9, 11 

artificial respiration in, 10 

direct insufflation in, 10 

preventive treatment of, 9 
Atrophic paralysis, acute, 282 
Aspiration of pleural cavity, technic 

of, 51 
Assimilation, infants differ in power 
of, 125 

most efficient in early infancy, 125 
Asthma, bronchial, 346 

thymic, 342 
Ataxia, Friedreich's, 483 

hereditary, 483 
Atelectasis, congenital, 11 
Athrepsia, 420, and see Marasmus 
Atrophic paralysis, acute, 282 
Atrophy, 150 

idiopathic muscular, 484 

infantile, 420, and see Marasmus 
Attitude, typical, of normal infant, 26, 

27 
Auroscope, electric, 535 
Auscultation of infants and children, 
44, 45 



Babinski's reflex, 45, 278 

Balanitis, 448 

Baldness, 557 

Barlow's disease, 418 

Basedow's disease, 403 

Basket crib for premature infant, 2 

Bastedo's rule for dosage, 63 

Bathing, in infancy, 23, 24 

Baths, alcohol sponge, 72 

artificial Nauheim, 72 

bed, 70 

brine, 71 

carbonic acid, 72 

hot, 71 

hot air, 71 

mustard, 72 

sheet, 70 

soothing, 72 

special, 71 

sponge, 70 

warm, 71 
Bed batts, 70 
Bednar's aphtha^, 171 
Beef juice, to make, 145 
Beef tea, to make, 145 
Bell's palsy, 478 

Biliary ducts, inflammation of, 211 
Birth, injuries during, 5 

palsies, 6 



Bladder, calculus in, 455 

diseases of, 454 

ectopia of, 508 

extrophy of, 508 

inflammation of, 454 

of infant, 31 

spasm of, 454 
Blennorrhea, urogenital, 448 
Blepharitis, 536 
Blood, 381 

cells, red, 381 
nucleated 382 
number of, 381 

corpuscles, white, 382 

corpuscular element of, 381 

counts, 53, 54 

diseases of, 381 

examination of, 53 

in feces, 49 

in urine, 431 

plates, 383 

pressure, 365 

smears, method of making, 54 
Blue disease, 366 
Boiler, double, 136 
Boils, 551 
Bone, caries of, 320 

congenital absence of, 5C8, 510 

fractures of, during birth. 6 

injuries to, during birth, 6 

swollen, 92 

tuberculosis of, 320 
Bowels, irrigation of, 74, 75 

regularity of, in infancy, 25 
Boys, height and weight of, 35 
Brain, abscess of, 490 

diseases of, 488 

tumors of, 490 
Branchial cysts, congenital, 506 

fistula, 506 
Breasts, preparation of, for lactation, 
100 

type of, preferable for wet nurs- 
ing, 106, 107 
Breast feeding, 99, and see Nursing 

importance of, 99 

intervals of, 100 

management of, 100 

not possible, 105 

preparation for, 100 

regularity of. 100 

scanty supply of milk, ]01 
Breast milk, examination of, 103 
for premature infants, 3, 4 
reaction of, 104 
specific gravity of, 103 

pumps, 104 

secretions, 94 

composition of, 94 
properties of, 94 



INDEX. 



561 



Breathing, abnormalities in, as aid to 
diagnosis, ST 
exercises in, 83 

mouth, in nasal obstruction, 87 
Breck feeder for premature infants, 3 
B right's disease, acute, 433 
Brine bath, 71 
Bronchial asthma, 346 

stenosis, 88 
Bronchiectasis. 302 
Bronchitis, acute, 343 

diagnosis, 344 

etiology, 343 

physical signs, 343 

prognosis, 344 

symptomatology, 343 

treatment, 344 
capillary, 347 
chronic, 344 
Bronchopneumonia, acute, 347 

aerotherapy in, 351 

clinical forms of, 350 

complicating the infectious dis- 
eases, 350 

complications of, 350 

course of, 351 

diet in. 352 

differential diagnosis of, 350 

hydrotherapy in, 352 

local applications in, 352 

medication in, 352 

pathology of, 347 

physical signs of, 348 

prognosis of, 351 

symptomatology of, 347, 349 

treatment of, 351 
tuberculous, 307 
Broths, to make, 145 
Brudz in ski's sign, 45, 279 
Buhl's disease, 15 
Buttermilk, 146, 148 

Calculi, renal, 430 

vesical, 455 
Calmette test for tuberculosis, 57 
Caloric value of foods, 149 
Calorie feeding, 148 
Calx chlorata, as a disinfectant, 301 
Canc-rum oris, 174 
Cap. ice. 70 

Capillary bronchitis, 347 
Caput succedaneum. 5 
Carbohydrates, diet preponderating in, 
165 

of cereals, 116 
Carbolic acid, as a disinfectant, 301 
Carbonic acid baths. 72 
Cardiac disorders, functional, 377 

instruments in diagnosis of, 380 
Cardiograph. 380 
36 



Caricle, 24 

Caries of bone, 320 

of spine, 320 
Catalysers, 143 
Catarrhal fever, acute, 262 
Central paralysis, during birth, 8 
Cephalhematoma, 5 
Cereal gruels, percentage, 130 
Cereals, 115 

carbohydrates of, 116 

preparation of, 136 

properties of, 115 
Cerebral abscess, 490 

palsies, infantile, 491 

paralysis, 457 

tumors, 490 
Cerebrospinal fever, 277 

fluid, examination of, 49 

meningitis, epidemic, 277 
Cereo, 136 
Cestodes, 201, 204 
Chalazion, 537 

Changes in features, as a sign of ill- 
ness, 61 
Chapin's cream dipper, 129, 130 

infant urinal, 425 

tongue depressor, 328, 329 
Chest, abnormal shape of, 88 

as aid to diagnosis, 88 
Chest wall, tumors of, 88 
Chickenpox, 236 

return to school after, 257 
Child, height of, 35 

mental growth of, 35 

moral growth of, 35 

relative measurements of, 29, 34 

weight of, 35 
Childhood, diet during later, 162 

growth during, 34 

pulse in, 43 

relation of neutrophiles to lym- 
phocytes in, 55 

respiration in, 39 
Children, auscultation of, 44, 45 

mensuration of. 46 

palpation of, 42 

percussion of, 46 

rectal examination of, 47 
Children's hospitals, diet lists for, 160 
Chlorid of lime, as a disinfectant, 301 
Chloroform anesthesia, 516 
Chlorosis, 384, 388 
Choked disk, 540 
Cholera infantum. 196 
Chondrodystrophy, fetal, 404 
Chorea. 460 

complications, 462 
course. 461 
diagnosis. 461 
etiology, 460 



562 



INDEX. 



Chorea, forms of, 463 
pathology, 460 
prognosis, 461 
symptoms, 461 
treatment, 462 

hereditary, 463 

Huntington's, 462 

insaniens, 463 

major, 463 

minor, 460 

Sydenham's, 460 
Choreiform affections, 463 
Chvostek's symptoms in tetany, 472 
Chylous ascites, 526 
Circulatory system, diseases of, 364 
Circumcision, 519 
Cirrhosis of liver, 213 
Claw-hand, 92 
Cleft-palate, 506 
Clothing, in infancy, 23 
Clubbed fingers, 92 
Club-foot, 510 

Colds, return to school after, 257 
Colic, 187 

Collapse, pulmonary, 345 
Colles' law, 267 
Colon, dilatation of, congenital, 195 

flushing the, 74, 75, 76 

irrigation of the, 74, 75, 76 
Colostrum, 94 
Compresses, 70 
Condensed milk, 114 

mixtures, 147 
Congenital absence of bones, 508, 510 

atelectasis, 11 

branchial cysts, 506 

deformity of hand, 508 

dilatation of colon, 195 

dislocation of hip, 508 

heart disease, 366 

hydrocephalus, 494 

infantile stridor, 342 

laryngeal stridor, 342 

malformations and deformities, 505 

rachitis, 417 
Congestion of liver, 212 

Conjunctivitis, acute, 536 

chronic, 537 

diphtheritic, 537 

granular, 537 

of the newiy born, 18 

return to school after, 257 
Constipation, 197 

diet in, 164 
Contralateral sign, 45 
Convulsions, 458 

description of the symptom com- 
plex, 459 

differential diagnosis, 459 

etiology, 459 



Convulsions, prognosis, 459 

treatment, 460 
Cow's milk, 109 

composition of, 109 

influence of breed on, 110 

influence of breed on composition 
of, 110 

one, 109 
Coxalgia, 322 
Cream, 113 

centrifugal, 113 

evaporated, 114 

gravity, 113 
Cream dipper, Chapin's, 129, 130 
Creches, diet lists for, 161 
Cretinism, 405 

differential diagnosis, 408 

etiology, 406 

prognosis, 408 

symptomatology, 406 

treatment, 410 
Cretins, 409, 410, 411 
Croup, 242 

catarrhal, 338 

false, 338 

spasmodic, 338 

diagnosticated from laryngismus 
stridulus, 341 

tent, 341 
Croupous pneumonia, 353, and see Lobar 

pneumonia 
Crying, as a sign of illness, 60 
Cryptorchidism, 452 
Culex mosquito, 294 
Curds, in stools, 186 
Cyanosis, 366 

in premature infants, 4 
Cystitis, 454 

vaccine therapy in, 82 
Cysts, branchial, congenital, 506 

Dactylitis, 92 

syphilitica, 269, 272 

tuberculous, 319 
Day nurseries, diet lists for, 161 
Dead born infant, 11 
Death due to prematurity, 1 

fetal, 11 
Deformities, congenital, 505 

exercises for developing children 
with, 80 

of head, 5 
Delayed growth as aid to diagnosis, 90 
Dentition, 31 

first. 32 

delayed, 32, 87 

disturbances of, 32 
Dermatitis, acute exfoliative, 545 

diagnosticated from scarlet fever, 
225 

exfoliativa neonatorum, 543 



INDEX. 



563 



Development of infant, 26, 28 
Dextri-maltose, 117 
Dextrinized gruel, to make, 144 
Diabetes insipidus, 430 

mellitus, 424 
Diacetonuria, 482 

Diagnosis, suggestive scheme for, 85 
Diarrhea, diet in, 164 

infectious, 188 

summer, 188 
Diet during later childhood, 162 

during second year, 157 

during third year, 159 

from third to sixth year, 160 
Dietary after the sixth year, 162 

during second year, 157 

for bottle weaned babies, 161 

for children of school age, 162 

for kindergartners, 161 

for runabouts, 161 

for special conditions, 163 

from 12 to 18 months, 158 

from 1 18 to 24 months, 158 

from 2 to 3 years, 159 

from 3 to 6 years, 160 
Diet lists, for children's hospitals, 160 

for day nurseries and creches, 161 
Digestive system, diseases of, 169 

tract, development of, 95 
diseases of, 176 ' 
Dilatation of colon, congenital, 195 

of stomach, 180 
Diphtheria, 238 

antitoxin. 244, 245 

complications. 243 

conjunctival, 243 

differential diagnosis, 240, 242 

diagnosis of, 48 

etiology, 238 

extubation. 249 

feeding of intubated cases, 250 

general treatment. 215 

immunization. 244 

intubation. 247 

laryngeal. 240 

local treatment, 246 

nasal, 243 

pathology, 239 

pharyngeal. 239 

prognosis, 244 

prophylaxis. 244 

pseudo-, 333 

return to school after, 257 

serum treatment. 245 

symptomatology, 239 

tonsillar, 239 

tracheotomy. 250 

treatment, 244 
Diphtheritic paralysis, 477 
Diplegia, spastic, 491 



Diplopia, 539 

Discharges, state of, as a sign of ill- 
ness, 61 
Disinfectants, 301 
Disinfection, 300 

of discharges, 300 

of room, 300 
Dislocation of hip, congenital, 508 
Dispensaries for infants' foods, 156 
Disseminated sclerosis, 482 
Dosage, 63, 64 

in vaccine therapy, 82 
Double boiler, 136 
Drugs, administration, 63 

dosage of, 63, 64 

elimination of, in milk, 101 

frequently used in pediatric prac- 
tice, 64 
Duchenne's paralysis, during birth, 7 

pseudohypertrophic muscular pa- 
ralysis, 484 

type of primary myopathy, 484 
Ductless glands, diseases of, 396 
Duke's disease, diagnosed from scarlet 

fever, 226 
Dysentery, amebic, 199 
Dyspepsia, 150 

acute, 176 
Dysphagia, false, 87 

true, 87 
Dyspnea, expiratory, 88 

inspiratory, 87 

mixed, 88 
Dystrophy, muscular, 484 

Eak, 531 

diseases of, 531 

speculum, 531, 532, 535 
Eating, ru^s for, 168 
Eclampsia infantum, 458, and see Con- 
vulsions 
Ectopia of bladder, 508 
Eczema, 545 

acute, treatment, 548 
general. 548 
local. 548 

chronic. 546 
treatment. 549 

crustosum, 546 

diagnosis, 546 

etiological factors, 545 

erythematous, 546 

madidans, 546 

mask, 548 

papular, 546 

prognosis. 547 

pustular. 546 

rubrum. 546 

subacute, treatment, 549 

subvarieties. 546 



564 



INDEX. 



Eczema, symptomatology, 546 

varieties, 546 

vesicular, 546 
Edema, acute circumscribed, 473 

angioneurotic, 473 

of glottis, 340 
Eggs, 116 

Ehrlich's preparation for syphilis, 273 
Eiweissinilch, to make, 145 
Emphysema, 345 

acute, 345 
Empyema, 356 

exploratory puncture, 358 

symptomatology, 357 

treatment, 359 
Encephalitis, acute, 489 
Encephalocele, 512 
Endocarditis, acute, 368 
diagnosis, 369 
etiology, 368 
pathology, 368 
prognosis, 369 
symptomatology, 368 
treatment, 370 

malignant, 369 

septic, 369 

ulcerative, 369 

vaccine therapy in, 81 
Endotoxins, 78 
Enemata, nutrient, 77 
Enlargement, general, 92 
Enteralgia, 187 
Enteroclysis, 74, 75, 76 
Enterocolitis, acute, 192 
Enuresis, 443 

psychotherapy in, 69 

treatment, 445 
Eosinophils, 382 
Eosinophilia, 55, 381, 383 
Epidemic cerebrospinal meningitis, 277, 
287 

hemoglobinuria, 15 

paralysis in children, 287 

parotitis, 255 
Epilepsy, 465 

diagnosis, 466 

etiology, 465 

grand mal, 465 

petit mal, 465 

prognosis, 466 

symptomatology, 465 

treatment, 466 
Epileptic voice sign, 466 
Epistaxis, 327 
Erb's myotonic reaction, 473 

paralysis during birth, 7 

symptom, in tetany, 472 

type of primary myopathy, 484 
Erysipelas, 297 

etiology, 297 



Erysipelas, prognosis, 299 

symptomatology, 298 

treatment, 299 
Erythema multiforme, 545 

scarlatinif orme, diagnosticated from 
scarlet fever, 225 
Erythemata, diagnosed from scarlet 

fever, 224 
Erythrocytes, 381, 382 
Esophagitis, corrosive, 176 
Esophagus, congenital occlusion of, 176 

inflammation of, see Esophagitis 

malformations of, 507 
Essential paralysis of children, 282 
Evaporated cream, 114 

milk, 114 
Examination of sick child, 39 

blank for, 40 
Examinations, special, 48 
Exanthemata, 214 

return to school after, 257 

table of, 237 
Exercise and fresh air in infancy, 24 
Exercises, breathing, 83 

for developing children with de- 
formities, 80 

for increasing respiratory capac- 
ity, 83 

resistant, 83 
Exophthalmic goiter, 403 
Exophthalmos, 539 
Exotoxins, 78 

Exploratory puncture in empyema, 358 
Expression of face, 86 
Extremities, as aid to diagnosis, 91 

enlargement of, 92 

rigidity of, 92 

spastic, 92 
Extrophy of bladder, 508 
Extubation, 249 

Exudates and transudates differenti- 
ated, 52 

examination of, 48 
Eye, affections of, diagnostic hints re- 
garding, 539 
diagnostic significance of, 538 

diagnostic hints regarding affection 
of, 539 

diseases of, 536 

foreign bodies in, 536 

test for tuberculosis, 57 
Face, as aid to diagnosis, 86 

expression of, 86 
Facial paralysis, 478 

during birth, 7 
Fat in milk, percentages of, in differ- 
ent portions of milk, 127 
Fatty degeneration of the newly born, 
15 

liver, 212 



IXDEX. 



565 



Favus, 556 

Features, changes in, as a sign of ill- 
ness, 01 
Feces, and see Stools 

blood in, 49 

examination of, 49 

ova, in, 49 
Feeblemindedness, 497, and see Idiocy 
Feeders for premature infants, 3 
Feeding, and see Infant Feeding, Nutri- 
tion 

calorie, 148 

directions, outline of, 132, 151 

forced, 76 

in bot weather, 154 

in typhoid fever. 261 

infant, chemical and biological 
standards in, 97 

laboratory, 148 

mixed, 105 

of intubated cases, 250 

of premature infants, 3, 4 

practical, 120 

rectal, 77 

substitute, see Substitute Feeding 

table, suggestive, 134 

utensils, care of, 153 

when away from home, 155 

when traveling, 154 
Fetal chondrodystrophy, 404 

death. 11 
Fever, acute catarrhal, 202 

cerebrospinal, 277 

rheumatic, 288 

spotted, 277 
Fingers, clubbed. 92 

webbed. 512, 513 
Finkelstein's classification of nutri- 
tional disorders, 150 
Fissure of anus. 520 

of mouth, 80 

of tongue, 87 
Fistula*, branchial, 500 
Fontanels, abnormal, 85 
Food, adaptation of, to infant, 138 

administration of. 152 

caloric value of, 149 

care of. in infant feeding, 151 

dispensaries, 150 

essential unity of. 93 

for acutely ill infants, 144 

for healthy infants. 132 

for infnnts, administration of, 152 

for infants of feeble constitution, 
142 

for infants previouslv badly fed, 
140 

for infants who fail to thrive on 
fresh milk, 140 

improper, cause of scorbutus, 418 



Food, of first nutritive period, 94 

specialized, 94 

values, caloric. 149 
Foot, club, 510 

Foot drop, in poliomyelitis, 284 
Forced feeding. 70 
Foreign bodies in eye, 53G 

in nose, 327 

in respiratory tract. 303 
Fourth disease, diagnosticated from 

scarlet fever. 220 
Fractures during birth, 
Freeman's pasteurizer, 152 
Fresh air, in infancy, 24 

in treatment of disease, 09 
Friedreich's ataxia, 483 
Functional cardiac disorders, 377 
Furunculosis, 551 

vaccine therapy in, 82 

Gait, observation of. 450 
Gangrene of lung, 3G1 
Gas-ether anesthesia, 517 
Gastric catarrh, acute, 170 

contents, examination of, 48 

indigestion, acute, 170 

ulcer, 177 
Gastritis, acute, 170 

chronic, 179 
Gastroenteritis, acute, 188 
Gastrointestinal indigestion, chronic, 

194 
Gavage, 70, 77 

danger of, in premature infants, 4 
Genital organs, diseases of, 447 
Geographic tongue. 109 
German measles. 219 

return to school after. 257 
Girls, height and weight of, 35 
Glands of infant, 31 
Glomerulonephritis, acute, 433 
Glossitis, desquamative, 109 
Glottis, edema of, 340 
Glycosuria. 424 
Goiter, exophthalmic. 403 
Gonitis tuberculosa, 323 
Grand mal, 405 
Graves' disease, 403 
Growth, delayed, as aid to diagnosis, 90 

during childhood, 34 

mental, of child. 35 

moral, of child, 35 

of infant, 27 
Gruels, cereal, percentage, 130, 135, 136 

dextrinized, to make, 144 

directions for making. 136 
Gums, bleeding, 87 

spongy, 87 

swollen. 87 



566 



INDEX. 



Habits, general, of infants, 25 
Hand, abnormal, 92 

claw, 92 

congenital deformity of, 508 

intra-uterine amputation of, 509 
Harelip, 505 
Head, as aid to diagnosis, 85 

deformity of, 5 

fontanels, abnormal, 85 

injury to, during birth, 5 

motion of, abnormal, 85 

of infant, 28, 29 

position of, abnormal, 85 

shape of, abnormal, 85 

size of, abnormal, 85 

tumors about, 85 
Headaches, 466 
Hearing, estimation of, 457 
Heart, 365 

beats, 366 

block, 380 

disease, congenital, 366 

diseases of the, 364 

enlargement of, 365 

functional disorders of, 377 

location of valves, 373 

palpitation of, 377 

radiography of, 364 

valvular disease of, 372 
aortic, 375 
mitral, 374 
prognosis in, 376 
treatment of, 376 
tricuspid, 376 
Height of child, 35 
Hematuria, 431 

Hematoma of sternocleidomastoid, 6 
Hemic murmurs, 377 
Hemiplegia, resulting from labor, 8 

spastic, 491 
Hemoglobin, estimation of, 53 
Hemoglobinometer, 53 
Hemoglobinuria, 431 

epidemic, 15 
Hemophilia, 394 
Hemorrhages, as aid to diagnosis, 90 

causes of, general, 90 
special, 91 

from nose, 91 

from rectum, 91 

into adrenals, 400 

of new born, 91 

of stomach, 91 

spontaneous, in the newly born, 20 

umbilical, 13 
Henoch's purpura, 393 
Hereditary ataxia, 483 

course, 484 

differential diagnosis, 484 

etiology, 483 



Hereditary ataxia, pathology, 483 

prognosis, 484 

symptomatology, 483 

treatment, 484 
Hernia, 517 

diagnosis, 518 

etiology, 517 

symptomatology, 517 

treatment, 518 

umbilical, 14 

Pisek's dressing for, 14 
Herpes zoster, 551 
Hip, congenital dislocation of, 508 

tuberculous disease of, 322 
Hip-joint disease, 322 
Hirschsprung's disease, 195 
History of sick child, 39 

blank for, 40 
Hives, 550 

Hodgkins' disease, 400 
Hook worm, 206 
Hoover breast pump, 104 
Hordeolum, 537 
Hot air bath, 71 
Hot baths, 71 
Hot pack, 71 

Hot weather, infant feeding in, 154 
Huntington's chorea, 463 
Hutchinson's teeth, 33, 274 
Hydrencephalocele, 512 
Hydrocele, 451 

congenital, 451 

encysted, of the cord, 451 

infantile, 451 

of tunica vaginalis, 451 
Hydrocephalus, 494 

acquired, 494 

classification of, 494 

congenital, 494, 495 

diagnosis, 496 

etiology, 495 

prognosis, 496 

symptomatology, 495 

treatment, 496 
Hydronephrosis, 442 
Hydrotherapy, 70 
Hygiene of infancy, 23 
Hymenolepis Nana, 206 
Hyperleukocytosis, 381, 383 
Hyperphonia, 474 
Hypertrophy of pylorus, congenital, 181 

of tonsil, 335 
Hypodermoclysis, 74 
Hypospadias, 508 
Hypostatic pneumonia, 353 
Hysteria, 463 

etiology, 463 

prognosis, 464 

psychotherapy in, 69 

symptomatology, 463 

treatment, 464 



IXDEX. 



567 



Ice cap. 70 

poultice, 70 
Icterus in premature infauts, 4 

neonatorum. 15 
Ichthyosis, 541 
Idiocy. 497 

etiology, 497 

prognosis. 498 

symptomatology, 49S 

treatment. 498 
Idiocy, amaurotic family, 501 

Mongolian, 499 
Idiots, tests for, 503 
Imbecility, 497, and see Idiocy 
Idiopathic muscular atrophy, 484 
Immunization, reation of. 78 
Impetigo contagiosa. 544 
Inability to walk. 91 
Incontinence of urine, 443 
Incubator, for premature infants, 1, 2 
Indican, test for, 52 
Indicanuria. 432 
Indigestion, gastric, acute, 176 

gastro-intestinal. chronic, 194 
Infancy, assimilation in, 125 

bathing in, 23, 24 

clothing in, 23 

exercise and fresh air in, 24 

general habits in, 25 

habits of sleep in, 25 

hygiene of, 23 

pulse in. 43 

regularity of bowels in, 25 

respirations in, 39 

sitrns of illness in, 60 

urine in, 425 
Infant, and see Newly born 

acutely ill. food for. 144 

adaptation of food to, 138 

appendix of, 31 

attitude of normal. 26. 27 

auscultation of. 44, 45 

bladder of. 31 

dead born. 11 

dentition of. 31 

development of, 26. 28 

difference of. in digestive and as- 
similative efficiency, 125 

glands of. 31 

growth of. 27 

head of. 28. 29 

healthy, food for. 132 

intestines of. 31 

lacrimal glands of. 31 

length of. 27 

liver of. 31 

loss of weight during first few 
days. 20 

mensuration of. 46 

muscles of, 31 



Infant, nucleated red cells in, 55 
nutrition of, 93, 97 
of feeble constitution, foods for, 

142 
pancreas of, 31 
percussion of, 46 

premature, see Premature infants 
previously badly fed, food for, 140 
rectal examination of, 47 
relative measurements of, 29 
salivary glands of. 31 
sebaceous glands of, 31 
shape of, 28 
skull of, 30 
spine of, 30 
stillborn, 11 
stomach of. 31 
teeth of, 31, 32, 33 
tendency of, to adapt themselves 

to their food, 124 
testicles of, 31 
thymus of, 31 
viscera of, 31 
weighing of, 26, 153 

importance of, 153 
weight and development of, 26 

chart. 154 
who fail to thrive on fresh milk, 
foods for, 146 
Infant feeding. 93 

among the poor, 155 
care of food, 151 

of utensils, 153 
chemical and biological standards 

in, 97 
directions for, 132, 151 
education of mother necessary. 151 
fundamental errors in, 121 
how to interpret results. 153 
in hot weather. 154 
methods of modifying milk for. 123 
percentage milk mixtures in. 126 
practical. 120 

basis of. 126 
scientific, rise and development of. 

121 
when away from home. 155 
when traveling. 154 
Infant foods, administration of, 152 
dispensaries. 150 
proprietary. 117 

classification of. 117 

composition of. 117 
Infantile atrophy. 420. and see Maras- 
mus 
cerebral palsies. 491 
paralysis. 282 
scurvy, 418 
stridor, congenital, 342 



568 



INDEX. 



Infantilism, 405 

Brissaud type, 405 

diagnosed from cretinism, 408 

Lorain type, 405 
Infarction, uric acid, 430 
Infectious arthritides, 293 

diarrhea, 188 

diseases, 214 

bronchopneumonia complicating, 

350 
disinfection in, 300 
of th newly born, 12 
sick room in, 300 
Inflammation of biliary ducts, 211 

of portal vein, 212 
Influenza, 262 

definition, 262 

diagnosis, 265 

etiology, 262 

incubation, 262 

pathology, 262 

symptomatology, 262 

treatment, 265 
Inguinal region, as aid to diagnosis, 90 

enlargement of, 90 

swellings in, differential diagnosis 
of, 452 

tumors of, 90 
Injuries during birth, 5 

to bone, 6 

to head, 5 

to muscle, 6 
Insomnia, 468 

Inspection of sick child, 39 
Insufflation, direct, in asphyxia, 10 
Intestines, of infants, 31, 75 

tumors of, 90 
Intoxication, 150 
Intubation, 247 
Intussusception, 521 

diagnosis, 522 

etiology, 522 

prognosis, 523 

symptomatology, 522 

treatment, 523 
Inunctions for premature infants. 4 
Inunction test for tuberculosis, 57 
Invagination, intestinal, 521 
Irrigation of bowel, 74, 75 
Irritability of temper, as a sign of ill- 
ness, 60 
Ischemic paralysis, Volkman's, 458 
Ischiorectal abscess, 526 
Itch, the, 554 
Itch mite, 555 
Ivy poisoning, 557 

Jaundice, 210, and see Icterus 
Joints, swollen, 92 

tuberculosis of, 320 
Jugular bulb infection, 534 



Keratitis, 538 
Kernig's sign, 278 

method of eliciting, 43, 44 
Kidney, amyloid, 438 

congestion of, 432 
chronic, 432 

disorders of, 425 

formation of, 429 

large white, 438 

passive hyperemia of, 432 

tumors of, 89, 441 

waxy, 438 
Kilmer belt for pertussis, 254 
Knee, tuberculous disease of, 323 
Koplik's spots, 215 

Laboratory feeding, 148 
Laborde's method of artificial respira- 
tion, 11 
Lacrimal glands of infant, 31 
La Grippe, 262 
Landouzy-Dejerine type of primary 

myopathy, 484 
Laryngeal stenosis, 88 

stridor, congenital, 342 
Laryngismus stridulus, 340 
Laryngitis, acute, 338 

diagnosticated from laryngismus 
stridulus, 341 

diphtheritic, diagnosticated from 
acute laryngitis, 339 

spasmodic, 338 

submucous, 340 
Larynx, new growths of, 342 

papilloma of, 342 
Lavage, 73 
Length of infant, 27 

premature infant, 2 
Leptomeningitis, acute, 488 
Leukemia, 385 

lymphatic, 386, 388 

splenomyelogenous, 385, 388 
Leukocytes, 381, 382 

number of, 381 
Leukocytosis, 381, 383 
Leukopenia, 381, 383 
Limp, walking with, 91 
Lip, hare-, 505 
Lips, enlarged, 86 
Liver, 209 

abscess of, 213 

amyloid, 212 

cirrhosis of, 213 

congestion of, 212 

diseases of, 209 

enlarged, 89 

examination of, 209 

fatty, 212 
Liver of infant, 31 
Lobar pneumonia, 353 

complications, 354 



IXDEX. 



569 



Lobar pneumonia, diagnosis, 354 

etiology. 353 

pathology, 353 

physical signs, 354 

prognosis. 354 

symptomatology, 354 

treatment, 354 

vaccine therapy in, SI 
Lobular pneumonia, 347 
Logi's method of breathing. 83 
Luetin test for syphilis. 59 
Lumbar puncture in cerebrospinal men- 
ingitis, 279. 282 

technic of. 50. 51 
Lungs, abscess of, 361 

diseases of, 343 

gangrene of, 361 
Lymphadenoma. 400 
Lymphocytes. 382. 383 

in childhood, 55 
Lymphocytosis, 381, 383 

MacEwex's sign, 279 
Macrosfiossia, 86 
Malaria. 294 

diagnosis of, 56 

differential diagnosis, 296 

etiology, 294 

pathology. 295 

prophylaxis. 296 

symptomatology, 295 

treatment, 296 
Malformations, congenital, 505 

of anus. 507 

of esophagus. 507 

of rectum, 507 
Malignant tumors in children. 52S 
Mammala, 115 
Mammary secretions comparative, 96, 

and see Milk 
Marasmus, 420 

course, 422 

diet in, 422 

etiology. 420 

medication. 423 

pathology. 420 

prognosis, 422 

symptomatology, 421 

treatment, 422 
Mask, erzenia. 548 
Mast cells, 382 

Mastitis of the newly born, 19 
Mastoiditis, 533 

vaccine therapy in, 82 
Masturbation. 450 
Measles. 214 

complications, 216 

definition. 214 

eruption. 216 

etiology, 214 



Measles, exanthem, 216 
fever, 216 
German, 219 
incubation, 215 
Koplik's spots, 215 
pathology, 215 
prodromal stage, 215 
prognosis, 218 
prophylaxis, 218 
return to school after, 257 
sequela?, 216 
treatment, 218 
variations, 216 
Measurements, physical, 34 
relative, of infant, 29 
of child, 29, 30 
Meat broths, to make, 145 
Megaloblast, 381, 382 
Melena neonatorum, 21 
Meningeal apoplexy, during birth, 8 
Meningitis, 488 

diagnosis, 489 
etiology, 488 
leptomeningitis, 488 
pachymeningitis, 488 
symptomatology, 488 
treatment, 489 
epidemic cerebrospinal, 277 
complications, 280 
differential diagnosis, 280 
etiology, 277 

lumbar puncture in, 279, 282 
pathology, 277 
prognosis, 280 
serum treatment, 281 
symptomatology, 277 
treatment, 281 
influenzal. 266 
tuberculous, 312 
Meningocele. 512. 514 
Mensuration of infants and children, 46 
Mental deficiency, tests for. 502 
Mental growth of a child, 35 
Microblast, 381 
Microcephalia, 497, 498 
Microcyte. 382 
Migraine, 467 
Miliaria. 550 
Miliary tuberculosis, acute. 311 

of lungs. 308 
Milk, and see Mammary secretions 
and water percentages, 131 
bacteriologv of. 110 
bottled. 111 
certified. 111 
commissions, 111 
condensed, 114 
mixtures, 147 
cows'. 109 
crust. 544 



570 



INDEX. 



Milk, eliminatioon of drugs in, 101 

evaporated, 114 

grocery, 111 

human, normal, 94 

inspected, 111 

market, 111 

microscopical appearance of, 113 

mixtures, percentage, in infant 
feeding, 126 

modification of, approximate, 137, 
138 

modified, 123 

classification of methods em- 
ployed, 123 

mother's disagrees with infant, 102 
drugs eliminated in, 101 
insufficient, 101 

one cow's, 109 

pasteurized, 112 

peptonized, 148 

percentages of fat, in different por- 
tions of, 127 

sanitary, 111 

production of, 110 

sterilized, 112 

top, 127 
Mitral obstruction, 374 

regurgitation, 374 
Modified milk, 123 

classification of methods, 123 

for premature infants, 3 
Moles, 543 
Mongolian idiocy, 499 

diagnosticated from cretinism, 408, 
500 
Moral growth of child, 35 
Morbilli, 214, and see Measles 
Morbus coxae, 322 
Moro test for tuberculosis, 57 
Morons, test for, 504 
Mosquitoes, 294 
Motion, disturbances of, 91 
Mouth, as aid to diagnosis, 86 . 

breathing in nasal obstruction, 87 

diseases of, 169 

fissures of, 86 

inflammation of, see Stomatitis 

open, 86 

putrid sore, 173 

ulcerations of, 86 

white, 172 
Movements, purposeless involuntary, 92 
Mucus in stools, 186 
Multiple neuritis. 476 

sclerosis, 482 
Mumps, 255 

complications, 256 

differential diagnosis, 256 

etiology, 255 

pathology, 255 



Mumps, prognosis, 256 

return to school after, 257 

symptomatology, 255 

treatment, 256 
Murmurs, hemic, 377 
Muscles, injuries to, during birth, 6 

of infants, 31 

paralysis of, 458 
Muscular atrophy, idiopathic, 484 

dystrophy, 484 

paralysis, pseudohypertrophic, of 
Duchenne, 484 
Mustard bath, 72 
Myelitis, 480 

diagnosis, 482 

etiology, 480 

pathology, 480 

prognosis, 482 

symptomatology, 480 

treatment, 482 
Myelocytes, 382 
Myocarditis, 370 
Myopathy, primary, 484 

complications, 487 

differential diagnosis, 487 

etiology, 484 

pathology, 485 

symptomatology, 485 

treatment, 487 

types of, 484 
Myotonia congenita, 472 
Myotonic reaction, of Erb, 473 
Myxedema, 405, and see Cretinism 

Nasal obstruction, mouth breathing in, 

87 
Nasopharyngeal toilet, the, 73 

in scarlet fever, 228 
Nauheim baths, artificial, 72 
Neck, as aid to diagnosis, 86 

tumors about, 86 
Nematodes, 201 
Neosalvarsan, 273 
Nephritis, 433 
acute, 433 

complications, 436 
definition, 433 
diagnosis, 436 
etiology, 433 
pathology, 433 
prognosis, 436 
symptomatology, 434 
synonyms, 433 
treatment, 436 
desquamative, 433 
diffuse, 433 
exudative, 433 
glomerulo-, 433 
parenchymatous, 433 
tubular, 433 



INDEX. 



571 



Nephritis, chronic, 43S 

complications, 439 
definition, 43S 
diagnosis, 439 
etiology, 438 
pathology, 438 
prognosis, 439 
symptomatology, 438 
synonyms, 438 
treatment, 439 
diffuse. 43S 
interstitial, 438 
parenchymatous, 438 
Nerve paralysis, 458 
Nerves, peripheral, diseases of, 476 
Nervous diseases, general. 456 

system, diseases of, 456 
Nettle rash, 550 
Neuritis, multiple. 476 
course, 477 
definition, 476 
diagnosis, 476 
etiology, 476 
prognosis, 477 
symptomatology, 476 
pathology, 476 
treatment, 477 
optic. 540 
Neutrophils in childhood, 55 
Nevi. 543 

New growths of larynx, 342 
Newly-born, and see Infant 

acute infectious diseases of the, 12 
conjunctivitis of the, 18 
dimensions of, 26 
diseases of the, 12 
epidemic hemoglobinuria in, 15 
fatty degeneration of the, 15 
hemorrhages of, 91 
icterus of, 15 
mastitis of, 19 
ophthalmia of, 18 
sclerema of, 19 
sepsis of the. 12 

spontaneous hemorrhages in the, 20 
tetanus of, 17 

umbilical hemorrhage of, 13 
Night terrors, 469 
Nipple shield, 105 

Noguchi's method of examining cerebro- 
spinal fluid, 50 
test for syphilis, 58 
Noma. 174 

Normoblast, 381, 382 
Nose, bleeding from, 91. 327 

foreign bodies in. 327 
Nucleated red eells in infants, 55 
Nursery, the. 24 
Nursinsr. and see Breast feeding 
bottle, 152 



Nursing, contraindications for, 105 

not possible, 105 
Nutrition, and see Feeding. . 

difference of infants in capacity for, 
125 

diseases of, 412 

of infant, 93 

of premature infants, 3 
Nutritional disorders, 412 

Finkelstein's classification of, 150 
Nystagmus, 539 

Obesity, diet in, 165 

Occlusion of esophagus, congenital, 176 

Ophthalmia neonatorum, 18 

Opsonins, 79 

Optic neuritis, 540 

Otitis, 532 

vaccine therapy in, 82 
Otoscopy, 531 
Ova in feces, 49 
Oxyuris vermicularis, 201 

Pachymeningitis, 488 
Packs, hot, 71 
Palate, cleft, 506 
Palpation of sick child, 42 
Palpitation of heart, 377 
Palsies, birth, 6 

classification of, 492 
infantile cerebral, 491 
classification, 492 
diagnosis, 494 
etiology, 491 
pathology, 491 
symptoms, 492 
treatment, 494 
Palsy, Bell's, 478 
cerebral, 285 
peripheral. 285 
spinal, 285 
Paludism, 294 
Pancreas of infant, 31 
Papillitis, 540 
Papilloma of larynx, 342 
Paralysis. 91, 457 

acute atrophic, 282 

wasting, 282 
central, during birth. 8 
cerebral. 457 
diphtheritic, 477 
Duchenne's, during birth, 7 
epidemic, in children, 287 
Erb's during birth, 7 
essential, of children, 282 
facial. 478 

during birth. 7 
general characteristics of the vari- 
ous types, 457 
in general, 457 



572 



INDEX. 



Paralysis, infantile, 282 

ischemic, Volkmann's, 458 

muscle, 458 

nerve, 458 

postdiphtheritic, 243 

pseudo-, 91, 458 

spinal, 457 

upper-arm, during birth, 7 
Paramyoclonus multiplex, 473 
Paraphimosis, 447 
Paraplegia, spastic, 457, 491 
Parasites, animal, 201 

found in childhood, 201 
Parasitic protozoa, 201 

skin diseases, 554 
Parotitis, epidemic, 255 
Pasteurized milk, 112 
Pasteurizer, 152 
Patellar reflex, 44 
Pavor nocturnus, 469 
Pediculosis, 554 
Pediculus capitis, 554 
Pellagra, 552 

Pemphigus neonatorum, 543 
Peptonized milk, 148 

for premature infant, 4 
Percentage cereal gruels, 130 

milk mixtures, in infant feeding, 
126 
Percussion of infants and children, 46 
Pericarditis, 378 

diagnosis, 379 

etiology, 378 

pathology, 378 

physical signs, 378 

prognosis, 379 

symptomatology, 378 

treatment, 379 
Pericardium, diseases of, 378 
Peripheral nerves, diseases of, 476 
Peritonitis, acute, 523 
diagnosis, 525 
in early life, 524 
in the new born, 523 
prognosis, 525 
symptomatology, 523 
treatment, 525 

gonorrheal, 524 

pneumococcic, 524 

tuberculous, 315 
Peritonsillar abscess, 338 
Perleche, 172 
Pertussis, 251 

aerotherapy in, 254 

complications, 253 

course, 253 

diet in, 255 

drugs for, 254 

etiology, 251 

Kilmer belt for, 254 



Pertussis, pathology, 252 

primary stage of, 252 

prognosis, 253 

recession of symptoms, 253 

return to school after, 257 

spasmodic stage, 252 

symptomatology, 252 

treatment, 253 

vaccine treatment, 255 
Petit mal, 465 
Pharyngeal stenosis, 87 

tonsil, hypertrophy of, 335 
Pharyngitis, acute, 331 

in infants, 329 
treatment, 330 
Phimosis, 447 
Photophobia, 530 
Physical measurements, 34 
Pisek's dressing for umbilical hernia, 14 

reversible stethoscope, 45 
Plaques, blood, 383 
Plates, blood, 383 
Pleura, diseases of, 343 
Pleural cavity, aspiration of, technic 

of, 51 
Pleurisy, 355 

dry, 355 

serofibrinous, 355 
pathology, 355 
physical signs, 355 
prognosis, 356 
symptomatology, 355 
treatment, 356 
Pneumonia, catarrhal, 347 

croupous, 353, and see Lobar pneu- 
monia 

hypostatic, 353 

lobar, 353, and see Lobar pneu- 
monia 

lobular, 347 

vaccine therapy in, 81 
Pneumothorax, 361 
Poikilocytosis, 381 
Poliomyelitis, 282 

definition, 282 

diagnosis, 285 

epidemic form of, 287 

etiology, 282 

pathology, 283 

prognosis, 286 

symptomatology, 283 

treatment, 286 
Polygraph, 380 
Polynuclears, 382 

in childhood, 55 
Polynucleosis, 381 
Polypus, rectal, 526 
Polyuria, 429, 430 
Portal vein, inflammation of, 212 
Postdiphtheritic paralysis, 243 



INDEX. 



5?a 



Posture, in primary myopathy, 486 
Pott's disease. 320 

cervical. 321 

dorsal, 321 

lumbar. 321 
Poultice, ice, 70 
Practical feeding, 126 

basis of. 126 
Premature infants, breast milk for, 3, 4 

care of, 1 

cyanosis in, 4 

danger of gavage in, 4 

death rate of. 1 

factors prejudicial to life of, 1 

feeders for, 3 

feeding of, 3, 4 

icterus in, 4 

incubators for, 1, 2, 4 

inunctions for, 4 

length of. 2 

management and care of, 1 

modified milk for, 4 

nutrition of, 3 

peptonized milk for, 4 

subnormal temperature of, 1, 2 

temperature of, 1, 2 

viability of, 1 

weight of, 2 
Prescriptions, 68 
Prickly heat, 550 
Primary myopathy, 484 
Profeta's law, 267 
Prolapse of anus, 527 

of rectum, 527 
Proprietary infant foods, 117 

classification of, 117 

composition of, 117 
Protozoa, parasitic, 201 
Pseudodysphagia, 87 
Pseudohvpertrophic muscular paralysis, 

484 
Pseudoleukemia, 400 

of infants, 386, 388 
Pseudoparalysis, 91, 458 
rseudotetany. 471 
Psoriasis, 549 
Psychotherapy, 69 
Ptosis. 539 
Pulmonary abscess, 361 

collapse. 345 

gangrene. 361 

tuberonlosis. 309 
Pulse, in infancy and childhood, 43 
Puncture, lumbar. 50, 51 

subdural, 50. 51 
Purpura. 391 

fulminans. 393 

hemorrhagica, 392 

Henoch's. 393 

rhenmatica, 393 



Purpura, Schonlein's, 393 

simplex, 391 
Putrid sore mouth, 173 
Pyelitis, 440 

definition, 440 

diagnosis. 441 

etiology, 440 

pathology, 440 

prognosis, 441 

symptomatology, 440 

treatment, 441 

vaccine, therapy in, 82 
Pylephlebitis, suppurative, 246 
Pyloric spasm, 181 
Pylorus, hypertrophy of, congenital, 181 

stenosis of, 181 

Quinsy, 338 

Rachitic spine, 321 
Rachitis, 412 

antenatal, 417 

bones in, 412, 414, 415 

congenital, 417 

course, 416 

deformities in, 415 

diagnosed from syphilis, 272 

diagnosis, 416 

deformities in, 415, 417 

dietetic treatment of. 417 

epiphyseal enlargements, 415 

etiology, 412 

Harrison's groove. 415 

hygienic treatment of, 417 

medication in. 417 

nervous phenomena in, 415 

pathology of, 412 

prognosis of. 416 

prophylaxis, 416 

spine in, 416 

spleen in, 413 

symptomatology of, 413 

thorax in, 415 

treatment of, 416 
Radius, congenital absence of, 510 
Reaction of immunization, 78 
Rectal examination of infants and chil- 
dren, 47 

feeding, 77 

polypus, 526 

syringe for infants. 199 
Rectum, hemorrhages from, 91 

malformations of. 507 

obstruction of. 507 

prolapse of, 527 
Renal calculi. 430 
Resistant exercises, 83 
Respiration, artificial, methods of. 10 
in infancy and childhood, 39 



574 



INDEX. 



Respiratory capacity, exercises for in- 
creasing, 83 

tract, foreign bodies in, 363 
upper, diseases of the, 326 
Restless sleep, as a sign of illness, 61 
Retropharyngeal abscess, 338 
Reversible stethoscope, 45 
Rheumatic fever, 288 ■ 
Rheumatism, acute articular, 288 

complications, 289 

differential diagnosis, 290 

drugs for, 291 

etiology, 288 

prognosis, 290 

prophylaxis, 291 

symptomatology, 289 

treatment, 291 
Rheumatoids, 293 
Rhinitis, acute, 326 
Rhus poisoning, 557 
Rickets, 412, and see Rachitis 

diagnosed from cretinism, 408 
Rigid extremities, 92 
Ringworm of scalp, 555 

of tongue, 169 
Ritter's disease, 543 
Rocking of infants, undesirable, 25 
Roentgen rays, 52 
Rotheln, 219 
Round worm, 202 
Rubella, scarlatiniform, diagnosticated 

from scarlet fever, 226 
Rubeola, 214, 219, and see Measles 

Salivary glands of infant, 31 

Salt-rheum, 545, and see Eczema 

Sarcoma, 528 

Scabies, 554 

Scalp, ringworm of, 555 

Scarlatina, 220, and see Scarlet fever 

Scarlet fever, 220 

anginal form, 221 

complications of, 229 

definition, 220 

desquamation, 221, 223 

desquamative stage, 227 

diet in, 228 

differential diagnosis, 224 

eruptive stage, 227 

etiology, 220 

incubation, 220 

pathology, 220 

predesquamative stage, 227 

1 re-eruptive stage of, 227 

prognosis, 227 

prophylaxis, 228 

rash, 222 

return to school after, 257 

sequela? of, 229 

serum treatment of, 230 



Scarlet fever, sick room, 228 
simple form, 220 
symtomatic treatment, 229 
symptomatology, 220 
treatment, 228 
vaccine therapy in, 79 
Schonlein's purpura, 393 
Schultze's method of artificial respira- 
tion, 10 
Sclerema neonatorum, 19 
Sclerosis, disseminated, 482 

multiple, 482 
Scorbutus, 418 

aggravated cases, 419 
course, 419 

dietetic treatment of, 420 
diagnosis of, 419 
etiology of, 418 
mild cases, 418 
pathology of, 418 
prognosis of, 419 
prophylaxis of, 419 
symptomatology of, 418 
treatment of, 419 
Scurvy, infantile, 418 
Sebaceous glands of infant, 31 
Seborrhea capitis, 544 
Secretions, breast, 94 
Sepsis of the newly born, 12 
Septic rashes diagnosed from scarlet 

fever, 226 
Septicemia, vaccine therapy in, 81 
Septicopyemia, vaccine therapy in, 81 
Serum, method of collecting for tests, 
57 
rashes, diagnosed from scarlet 
fever, 226 
Sheet baths, 70 
Shingles, 551 

Sick child, examination of, 39 
blank for, 40 
history of, 39 

blank for, 40 
inspection of, 39 
palpation of, 42 
to take temperature of, 41 
Sick room, in infectious diseases, 300 
Signs of illness in infancy, 60 
Sinus thrombosis, infective cerebral, 534 
Skin, diseases of, 541 

parasitic, 554 
Skin test for tuberculosis, 56 
Skull of infant, 30 
Sleep, amount required, 468 
habits of, in infancy, 25 
loss of, 468, and see Insomnia 
restless, as a sign of illness, 61 
Smallpox, 230 

complications, 232 
definition, 230 



IXDEX. 



575 



Smallpox, etiology, 230 

exanthein, 231 

incubation, 231 

prodromal stage, 231 

pathology, 231 

prognosis, 233 

prophylaxis. 233 

sequela?, 232 

symptomatology, 231 

treatment. 233 

variations, 232 
Soor. 172 
Soothing bath. 72 
Sore mouth, putrid. 173 

throat, streptococcic, 333 
Spasm, pyloric. 1S1 

vesical, 454 
Spasmodic croup, 338 
Spastic diplegia. 491 

extremities, 92 

hemiplegia. 491 

paraplegia. 491 
Special examinations, 48 
Specialized foods. 94 
Speculum, ear. 532. 535 
Spina bifida. 514 
Spinal cord, diseases of. 480 

inflammation of. see Myelitis 
Spinal paralysis. 457 
Spine, caries of, 320 

of infants. 30 

rachitic. 321 
Spleen, chronic passive congestion of, 
400 

diseases of. 399 

enlarged. 89 

enlargement of. 400 

inflammation of, 399 
Spondylitis. 320 
Sponge baths, 70, 72 
Spontaneous hemorrhages in the newly- 
born, 20 
Spotted fever. 277 
Sprue, 172 

Sputum, examination of, 48 
Squint, 538 
Stammering. 474 
Status lymphaticus, 396 
Stenosis, bronchial, 88 

laryngeal, 88 

of pylorus. 181 

pharyngeal, 87 

tracheal, 88 
Sterilized milk. 112 
Sternocleidomastoid, hematoma of, 6 
Stethoscope. Pisek's reversible, 45 
Stillborn infant. 11 
Still's disease. 294 
Stomacace. 173 



Stomach, dilatation of. 180 

hemorrhages from. 91 

inflammation of, see Gastritis 

of infant, 31 

tumors of. 90 

ulcer of, 177 

washing, 73 
Stomatitis, aphthous, 171 

catarrhal, 170 

follicular, 171 

gangrenous, 174 

herpetic, 171 

maculofibrinous, 171 

mycotic, 172 

parasitic. 172 

simple, 170 

ulcerative, 173 

vesicular, 171 
Stools, 185, and see Feces 

character of, as a sign of illness, 62 

examination of, 153, 185 

of artificially fed infants, 185 
Strabismus, 538, 539 
Streptococcic sore throat, 333 
Stridor, congenital infantile, 342 

laryngeal. 342 
Stripping®, 103 
Strophulus, 550 
Stuttering. 474 

St. Vitus' dance, 460, and see Chorea 
Stye. 537 

Subdural puncture, technic of, 50, 51 
Subphrenic abscess, 363 
Substitute feeding. 108 

difficulties of, 108 

material used in, 108 

principles of, 108 
Suggestion, in treatment of disease. 69 
Summer complaint. 188 

diarrhea, 188 
Supernumerary thumb, 513 
Surgical diseases, 516 
Sutures of skull. 29 
Swallowing, as aid to diagnosis. 87 
Swellings in inguinal region, differen- 
tial diagnosis of, 452 

of extremities. 1(2 
Sydenham's chorea, 460 
Syndactylism, 512 
Syphilis, 266 

acquired, 276 

congenital, 266, and see Syphilis, 
hereditary 

definition, 266 

diagnosed from tuberculosis. 272 

Ebrlich's preparation for, 273 

hereditary. 20(1 
Colles' law. 267 
definition. 206 

diagnosis, 272 



576 



INDEX. 



Syphilis, hereditary, inetnod of trans- 
mission, 267 
pathology, 267 
Profeta's law, 267 
prognosis, 273 
symptomatology, 269 
treatment, 273 
late hereditary, 274 

Hutchinson's teeth, 274, 275 
treatment, 276 
luetin test for, 59 
Wassermann test for, 57, 58, 267 
Syphilitic dactylitis, 269, 272 
Syringe, aspirating, 358 
rectal, for infants, 199 

Talipes, 510 

acquired, 510 

calcaneus, 511 

congenital, 510 

equinus, 511 

treatment, 511 

valgus, 511 

varus, 511 
Tape worms, 204 

armed, 205 

beef, 205 

dwarf, 206 

pork, 205 
Teeth, abnormalities, 87 

Hutchinson's 33, 274 

of infant, 31 

temporary, care of, 33 

permanent, 33 
Temper, irritability of, as a sign of 

illness, 60 
Temperature of premature infant, 1 

to take, 41 
Tenia mediocanellata, 204, 205 

saginata, 204, 205 

solium, 204, 205 
Terrors, night, 469 
Testicle, undescended, 452 
Testicles of infant, 31 
Tetanilla, 469, and see Tetany 
Tetanus neonatorum, 17 
Tetany, 469 

differential diagnosis, 472 

etiology, 469 

prognosis, 472 

symptomatology, 470 
Tetany, treatment, 472 
Tetter, 545, and see Eczema 
Therapeutics, general, 63 
Therapy, vaccine, 78 
Thomsen's disease, 472 
Thoracentesis, 358 
Thoracic tuberculosis, 307 
Thread worms, 201 

Throat examination of, in infants, 328, 
330 



Thrombosis, sinus, infective cerebral, 

534 
Thrush, 172 

Thumb, supernumerary, 513 
Thymic asthma, 342 
Thymus, 396 

enlargement of, 396 

of infant, 31 
Tics, 473 

differential diagnosis, 474 

treatment, 474 
Tinea favosa, 556 

tonsurans, 555 
Toes, webbed, 512 
Tongue depressors, Chapin's, 328, 329 

enlarged, 86 

fissures of, 87 

geographic, 169 

inflammation of, see Glossitis 

ringworm of, 169 

ulcers of, 87 
Tongue-tie, 505 

Tonsillar hypertrophy, chronic, 335 
Tonsil, pharyngeal, hypertrophy of, 335 
Tonsillitis, acute follicular, 331 

diagnosed from diphtheria, 240 

in infants, 329 
treatment, 330 

ulceromembranous, 333 
Top milk, 127 
Toxins, 78 

Tracheal stenosis, 88 
Trachoma, 537 

Transudates, examination of, 52 
Traveling, infant feeding when, 154 
Tracheotomy, 250 
Trichina spiralis, 207 
Tricuspid regurgitation, 376 
Trousseau's symptom, in tetany, 471 
Tuberculin tests, 56, 57 
Tuberculosis, 302 

acute miliary, 311 
differential diagnosis, 312 
etiology, 311 

bone, 320 

diagnosed from syphilis, 272 

etiology, 302 

incipient, diagnosis of, 308 

joint, 320 

miliary, of lungs, 308 

of vertebra?, 320 
diagnosis, 320 
treatment, 321 

prophylaxis, 324 

pulmonary, 309 
acute form, 309 
etiology, 309 
physical signs, 310 
chronic, 310 
course, 311 



IXDEX. 



577 



Tuberculosis. pulmonary, subacute 
form. 309 
etiology, 309 
physical signs, 310 
tests for. 50, 57 

Calmette test, 57 

eye test. 57 

inunction tests, 57 

Moro test. 57 

skin test, 50 

von Pirquet test, 56 
thoracic. 307 

diagnosis, 308 

pulmonary lesions. 307 
treatment in general, 324. 325 
tuberculin tests in. 50. 57 
Tuberculous adenitis, 30-4 

course. 306 

diagnosis. 300 

prognosis, 300 

symptomatology, 304 

treatment. 306 
arthritis, 294 
bronchopneumonia, 307 
dactylitis, 319 
disease of hip, 322 

treatment. 323 
disease of knee, 323 

treatment. 324 
meningitis. 312 

course. 315 

diagnosis. 315 

etiology, 313 

prognosis. 315 

symptomatology, 313 

treatment. 315 
peritonitis. 315 

ascitic form. 310, 317 

caseating form. 310 

diagnosis, 317 

fibrous form, 310 

miliary form, 316 

symptomatology, 317 

treatment. 318 ' 

ulcerative form. 316 
Tumors about bead. 85 
about neck, 80 
malignant, in children, 528 

diagnosis. 520 

treatment. 530 
of abdomen, localized. 89 
of abdominal wall, 90 
of brain, 190 
of cbest wall. 88 
of inguinal region, 90 
of intestines. 00 
of kidney. SO. 441 
of stomach, 90 
Typboid fever. 258 
drugs in. 202 
etioloirv. 258 

37 



Typhoid lover, feeding in. 201 
hydrotherapy in, 201 
immunity in. 260 
laboratory te"stS for. 259 
pathology, 25s 
prophylaxis, 260 
symptomatology, 25S 
temperature curve in, 251) 
treatment, 260, 20] 
vaccine therapy in, 81, 200 
Widal test for. 50 

Ulcer, gastric, 177 
Ulcerations < f mouth, SO 

of tongue, 80 
Umbilical hemorrhages, 13 

hernia, 14 

Pisek's dressing for. 14 

region, abnormalities of, 90 

vegetations, 14 
Uncinaria duodenalis, 200 
Undescended testicle. 4.~>2 
Upper arm paralysis during birth, 7 
Uretbritis, 448 
Urinal, fcr infants. 42.1 
Urine, absence of. 429 

acetone in. 432 

albumin in. 431. ami see Albumi- 
nuria 

blood in. 431 

character of. 420 

as a sign of illness. 62 

diacetic acid in. 432 

disorders of, 425 

examination of. 51 

excess of. 429. 430 

hemoglobin in. 431 

incontinence of. 443 

indican in, 52, 432 

in infancy, 425 

quantity of. 51 

suppressi n i f. 429, and sec Anuria 

to collect, 425 
Urogenital blennorrhea, -its 
Uropoietic system, diseases of. 425 
Urticaria. 550 

brine bath in. 71 
Uvula, elongated, 17-"> 

Vaccination. 234 

description of normal course, 235 

method of. 234 

value of, 234 

variations and complications, 235 

when to vaccinate, 234 
Vaccine therapy, 78 

dosage in. 82 
Vaccinia, 235 
Vaginitis, specific, vaccine therapy in. 



578 



INDEX. 



Valves of heart, location of, 373 
Valvular disease of heart, chronic, 372 

aortic, 375 

mitral, 374 

prognosis, 376 

treatment, 376 

tricuspid, 376 
Varicella, 236 

Variola, 230, and see Smallpox 
Varioloid, 232 
Vegetations, umbilical, 14 
Vertebrae, tuberculosis of, 320 
Vesical calculus, 455 

spasm, 454 

Vincent's angina, 333 
Viscera of infant, 31 
Voice sign, epileptic, 466 
Volkman's ischemic paralysis, 458 
Vomiting, as a sign of illness, 61 

cyclic, 184 

periodic, 184 

recurrent, 184 
Von Jaksch's anemia, 386, 388 
Von Pirquet test for tuberculosis, 56 
Vulvo-vaginitis, 448 

treatment, 449 

vaccine treatment, 450 

Walk, inability to, 91 
with limp, 91 



Warm baths, 71 

Wassermann test for syphilis, 57, 58 
Wasting paralysis, acute, 282 
Water, in treatment of disease, 70 
Weaning and mixed feeding, 106 
Webbed fingers, 512 

toes, 512 
Weighing infant, 26, 153 

importance of, 153 
Weight, disturbances of, 150 

of child, 35 

of infant, 26 

of premature infant, 2 
Wet nurse, selection of, 107 
Whey, directions for making, 141 

and cream mixtures, 141 
White mouth, 172 

swelling, 323 
Whooping cough, 251, and see Pertussis 
Widal test for typhoid fever, 56 
Winckel's disease, 15 
Worms, hook, 206 

round, 202 

tape, 204 

thread, 201 

Xerodermia, 541 
X-rays, use of, 52 

Zoster, 551 



